Earlier treatment for asymptomatic severe aortic stenosis may save lives

Aortic stenosis (AS) is the most common type of heart valve disease in Canada. It affects up to 3% of people aged 65 and older. Aortic stenosis  occurs when your aortic valve becomes stiff and narrow, making it harder for blood to flow from your heart to the rest of your body.

There’s currently no medication that can stop AS from progressing. The only treatment is to replace the damaged valve, either through open-heart surgery (called SAVR – surgical aortic valve replacement) or a less invasive procedure using a catheter to insert the new valve (called TAVR/TAVI – transcatheter aortic valve replacement/implantation).

Many people with severe AS do not initially experience symptoms, but once they appear, the risk of complications increases, and timely intervention becomes essential for survival.

The big question: When to treat?

If you have severe AS with no symptoms, your cardiologist will usually recommend regular checks to monitor your condition. Treatment (either SAVR or TAVR/TAVI) isn’t typically offered until you meet certain criteria.

This “watch and wait” approach can be tricky; doctors must weigh the risks of treating too early against risk of waiting too long. It is very important to tell your health team about any new symptoms, such as shortness of breath, coughing and chest pain, fainting, palpitations and decrease in exercise tolerance.

Use our symptom tracker to record changes to your health.

New research is changing perspectives

Recent studies are challenging the traditional approach of delaying treatment until AS becomes severe and symptoms appear. They suggest that treating some patients earlier, before symptoms appear, could reduce the risk of death and prevent heart failure. The studies are:

  • RECOVERY trial: Looked at early open-heart surgery (SAVR) vs. monitoring in patients with critical AS and without symptoms.

  • AVATAR trial: Compared early SAVR with watchful waiting in similar patients.

  • EVOLVED trial: Studied early treatment (SAVR or TAVR) using imaging and blood tests to guide decisions in patients with severe asymptomatic AS and signs of heart scarring.

  • EARLY TAVR trial: Investigated early catheter-based treatment (TAVR) vs. monitoring in patients with severe asymptomatic AS.

What does this mean for patients?

Dr. Philippe Pibarot, a leading expert on heart valve disease and a Heart Valve Voice Canada board member, says the research highlights three key points:

  1. Early intervention may help – for some patients. The RECOVERY, AVATAR and EARLY TAVR trials showed that early treatment reduced death and hospital visits for heart failure (reduced heart function) in certain patients – especially those with more advanced disease and low surgical risk.

  2. Careful patient selection is essential. Not everyone with asymptomatic severe AS will benefit from early treatment. The EVOLVED trial, for example, did not show clear benefits for everyone, in particular, patients with heart scarring. We need better tools to tell which patients are at higher risk and need intervention sooner.

  3. Personalized decision-making is key. Until there are clearer guidelines, treatment decisions should be based on the severity of your valve disease, test results, personal health risk, and what matters most to you. Shared decision-making between a patient and their heart team remains critical to ensure the right treatment is offered at the right time.

  • Learn more about aortic stenosis.

  • Read a detailed summary of these clinical trials, prepared specially for Heart Valve Voice Canada.