ESC/EACTS vs. ACC/AHA Guidelines for Severe Aortic Stenosis: Key Points

Lee G, Chikwe J, Milojevic M, et al.
ESC/EACTS vs. ACC/AHA Guidelines for the Management of Severe Aortic Stenosis. Eur Heart J 2023;44:796-812.

The following are key points to remember from a state-of-the-art review that compares recommendations for severe aortic stenosis (AS) in the recent European versus American guidelines for the management of patients with valvular heart disease:

  1. Overview. The 2020 American College of Cardiology/American Heart Association (ACC/AHA) and the 2021 European Society of Cardiology/European Association for Cardiac and Thoracic Surgery (ESC/EACTS) guidelines for the management of heart valve disease have far more in common than they have differences in recommendations for the management of patients with severe aortic stenosis (AS).
  2. Differences. There are only three areas in which there are substantial differences in the recommendations:
    • Asymptomatic AS with reduced left ventricular ejection fraction (LVEF). Among asymptomatic patients with severe AS in whom intervention is considered based on reduced LVEF, the ESC/EACTS guidelines use an LVEF threshold of <55% in the absence of other evident cause, whereas the ACC/AHA guidelines use an LVEF threshold of 60% in the setting of progressively decreasing EF on three serial echocardiograms.
    • Tissue vs. mechanical surgical aortic valve replacement (SAVR). In the context of decision making between tissue and mechanical SAVR, and whereas both guidelines incorporate Heart Team discussion, preference of the informed patient, and contraindications to anticoagulation; ACC/AHA recommendations use age thresholds of <50 years for a mechanical valve and >65 years for a bioprosthesis and the ESC/EACTS guidelines use respective thresholds of <60 years and >65 years.
    • Transcatheter aortic valve replacement (TAVR) vs. SAVR age thresholds. Both guidelines highlight patient age as a major consideration for SAVR vs. TAVR. However, the ACC/AHA guidelines use age thresholds of <65 years or life expectancy >20 years to recommend SAVR and age >80 years or life expectancy <10 years to recommend TAVR, and the ESC/EACTS guidelines use respective thresholds of age <75 years and low surgical risk for SAVR and age ≥75 years for TAVR.
  3. Heart Team and risk assessment. Both guidelines stress the importance of the Heart Team in clinical decision making, and the use of the Society of Thoracic Surgery (STS) Predicted Risk of Mortality (PROM) calculator (along with other factors including clinical status, anatomy, patient preferences, frailty, and futility) for the assessment of surgical risk.
  4. Symptomatic high-gradient AS. Both guidelines recommend intervention for symptomatic patients with severe, high-gradient AS.
  5. Low-flow low-gradient (LFLG) AS. Both guidelines recommend dobutamine stress echocardiography to distinguish true-severe from pseudo-severe AS in the setting of LFLG AS with reduced LVEF, but the guidelines differ in that the ESC/EACTS guidelines recommend intervention in the absence of contractile reserve when cardiac computed tomography (CCT) calcium scoring confirms that AS is severe. The ACC/AHA guidelines primarily recommend SAVR for LFLG AS with reduced LVEF, whereas the ESC/EACTS guidelines imply that TAVR can be used among these patients. For patients with LFLG AS and normal LVEF, the ESC/EACTS guidelines recommend intervention using an integrated approach that includes CCT, and the ACC/AHA guidelines recommend intervention if AS is felt to be the most likely cause of symptoms.
  6. Asymptomatic AS. Both guidelines endorse exercise testing among asymptomatic patients with severe AS; in addition to a decline in exercise tolerance, both guidelines identify adverse prognosticators including Vmax >5 m/s, Vmax progression ≥0.3 m/s/year, or elevated B-type natriuretic peptide. Among asymptomatic patients with normal flow low gradient AS, both guidelines recommend follow-up rather than intervention.
  7. Bicuspid aortic valve. The ACC/AHA guidelines recommend SAVR for patients with bicuspid aortic valve, whereas the ESC/EACTS guidelines offer no formal recommendation but note that SAVR is more appropriate in the setting of bicuspid AS and in those with associated aortopathy.
  8. Nontransfemoral TAVR. The ESC/EACTS guidelines acknowledge the limited role of nontransfemoral TAVR, and the ACC/AHA guidelines note that transapical TAVR is associated with increased mortality and should be a last resort.

Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Diagnostic Imaging, Echocardiography, Exercise Test, Geriatrics, Heart Valve Diseases, Heart Valve Prosthesis, Natriuretic Peptide, Brain, Patient Care Team, Risk Assessment, Stroke Volume, Tomography, Emission-Computed, Transcatheter Aortic Valve Replacement

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