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June 23, 2021

Prevention and Mitigation of Heart Failure in the Treatment of Calcific Aortic Stenosis: A Unifying Therapeutic Principle

Author Affiliations
  • 1Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
  • 2Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, Tennessee
JAMA Cardiol. 2021;6(9):993-994. doi:10.1001/jamacardio.2021.2082

Residual risk from heart failure (HF) among patients with calcific aortic stenosis (AS) undergoing aortic valve replacement (AVR) represents a major obstacle to optimal patient outcomes in terms of survival and quality of life1 as well as a large economic burden. HF is the most common cause of hospitalization in the year after transcatheter AVR, with rates only slightly lower than in the year prior.2 The long-standing paradigm for clinical management of patients with AS can be distilled as (1) monitor asymptomatic patients with progressive AS during a variable latent period with serial echocardiography until the AS is severe; (2) once severe, AVR is recommended, usually after symptoms develop3; and (3) once AVR has been performed, the AS has been fixed. There has been no role for medical therapy specifically to treat AS or its consequences; AVR is the only definitive treatment, and management centers wholly on its timing. Perhaps a reframing of the clinical needs and evidence gaps could stimulate and accelerate progress to improve outcomes for this growing number of patients. We propose prevention and mitigation of HF as a unifying and organizing principle for the treatment of AS that would integrate the valve and ventricle, AVR and medical therapy, and the pre-AVR and post-AVR time periods.

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