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Sudden cardiac death in patients with aortic stenosis: maybe it is not the valve?

In symptomatic patients with severe aortic stenosis (AS), there is no question that aortic valve replacement (AVR) relieves symptoms and prolongs life. In asymptomatic patients, clinical decision making is less clear because of the need to balance the risks of intervention and a prosthetic valve against the risks of continued watchful waiting. On the other hand, symptom onset is inevitable in patients with severe AS—the decision is not whether but rather when to replace the valve.

The primary rationale for deferring AVR until a later date is the lack of evidence that AVR before symptom onset would improve longevity. In addition, the risks, discomfort and disability associated with a surgical or transcatheter procedure are postponed until a later date. Furthermore, if a mechanical AVR is chosen, delaying intervention reduces the length of time the patient is exposed to the risks and inconvenience of warfarin anticoagulation. If a bioprosthetic AVR is chosen, implantation later in life increases the likelihood that the valve will not deteriorate to the point of reintervention during the patient’s lifetime. Unfortunately, patients with AS do not have the option of a normal aortic valve; instead the diseased native valve is replaced with an imperfect prosthetic valve.

On the other hand, accumulating evidence from advanced imaging studies shows that aortic valve obstruction is associated with adverse changes in left ventricular (LV) structure and function, even in the absence of symptoms, which may not resolve after AVR.1 In addition, observational studies suggest that there may be an increased risk of sudden cardiac death in apparently asymptomatic patients with severe AS, although the magnitude and predictors of risk remain unclear.

In order to provide clarity about the risk of sudden death in asymptomatic adults with AS, Minners and colleagues examined the data from the Simvastatin and Ezetimibe in Aortic …