Will Asymptomatic and Moderate Aortic Stenosis Trials Change Timing of Intervention?

Key Trials and Findings

• Design: Randomized 901 asymptomatic patients with severe AS to early TAVR vs. surveillance.
• Findings: Early TAVR reduced death, stroke, or unplanned cardiovascular hospitalization (26.8% vs. 45.3%).
• Implication: Supports early intervention in asymptomatic patients.
• Reference: Généreux P, et al. EARLY TAVR. NCT03042104

• Design: Randomized 157 asymptomatic patients with severe AS to early SAVR vs. conservative management.
• Findings: Early SAVR reduced death, MI, stroke, or heart failure hospitalization (HR 0.46, p=0.02).
• Implication: Strong evidence for early surgical intervention.
• Reference: Banovic M, et al. Circulation. 2022;145(9):648–658. NCT02436655

• Design: Focused on asymptomatic patients with myocardial fibrosis (LGE on CMR).
• Findings: No significant difference in death or AS-related hospitalization; improved NYHA class with early AVR.
• Implication: Fibrosis-based risk stratification may not yet guide early intervention.
• Reference: Loganath K, et al. JAMA. 2025;333(3):213–221. NCT03094143

Expert Perspectives and Meta-Analyses

• Meta-analysis of four RCTs showed lower stroke, heart failure hospitalization, and unplanned cardiovascular hospitalizations with early intervention.
• Many "asymptomatic" patients are misclassified; stress testing reveals symptoms in up to 40%.
• Registry data show delayed intervention leads to poorer outcomes.
• Reference: Gahl B, et al. JAMA Cardiology. 2020;5(10):1102–1112. DOI

Guideline and Expert Commentary

• Current guidelines recommend AVR in asymptomatic patients only under specific conditions.
• New trial data challenge this, suggesting routine early AVR may be beneficial.
• Experts propose shifting from “watchful waiting” to “proactive intervention.”
• Reference: Nishimura RA, O’Gara PT, Bonow RO. JAMA Cardiology. 2025;10(6):523–524. DOI

Conclusion

• Recent trials favor earlier treatment to prevent adverse outcomes.
• Paradigm shift in guidelines and clinical practice may be imminent.
• Emphasis on early identification and timely referral to heart valve teams.

ref:2025081503