This editorial refers to 'A clinical risk score of myocardial fibrosis predicts adverse outcomes in aortic stenosis' † , by C.W. Chin et al., on page 713. With the ageing of the population and increased use of echocardiography, aortic stenosis (AS) has become one of the most common valvulopathies encountered in the general population 1 . Current guidelines 2,3 advocate aortic valve replacement (AVR) for severe AS patients in the presence of either: (i) classical symptoms (angina, syncope, or

more »

... rtional dyspnoea) often difficult to ascertain in these patients with several co-morbidities; and/or (ii) left ventricular (LV) systolic dysfunction (i.e. LV ejection fraction ,50%) which could be permanent. While for symptomatic patients with severe AS the decision to treat is relatively simple, the timing for prophylactic intervention in an asymptomatic patient with preserved LV systolic function remains controversial and a matter of continuous debate. 4, 5 Should we then focus on the asymptomatic patients? For these patients, the two main concerns are the small risk of sudden cardiac death ( 1%/year) and the potential development of subclinical LV dysfunction. The current guidelines emphasize the role of objective assessment of functional capacity and symptomatic status with supervised exercise testing, which, although important, might not be feasible in some patients. In the absence of unmasked symptoms and/or markers of increased risk such as hypotension and/or failure of blood pressure to increase with exercise, the approach of watchful waiting with close surveillance for symptoms development seems reasonable. However, there is a marked heterogeneity, with subsets of patients at higher risk for development of symptoms and/or LV dysfunction that could potentially benefit from early AVR provided there is low surgical risk. Those would include asymptomatic patients with high peak aortic valve jet velocity .5.0 m/s 3 or .5.5 m/s in the European guidelines 2 (Class IIA) which also considered important for decision 'marked elevation of BNP on repeated measurements, mean AV gradient increase .20 mmHg with exercise, and excessive LV hypertrophy in the absence of hypertension' (Class IIB). 2