Assessment of aortic valve disease - a clinician oriented review

Table 3 Suggested high-risk criteria in asymptomatic severe aortic stenosis

Test	High risk criteria
Electrocardiogram	Presence of LV hypertrophy with secondary ST segment deviation ("LV strain")
Blood tests	Highly increased BNP/Nt-ProBNP levels
Stress test	Unmasked symptoms: Fatigability/dyspnea at < 75 W, syncope/near syncope; angina
	Lack of increase in systolic blood pressure by > 20 mmHg (or decrease) with exercise
	Inducible myocardial ischemia (ST segment depression ≥ 2 mm)
	Severe ventricular arrhythmias (sustained VT, polymorphic VT, VF)
Conventional Doppler echocardiography	Very severe AS (AVA ≤ 0.6 cm; maximal velocity ≥ 5 m/s)
	LVEF < 50%
	Severe LV hypertrophy (≥ 15 mm)?
	Reduced LV longitudinal strain
	Zva ≥ 4.5 mmHg/mL per square meters
Dobutamine stress echocardiography (in low-flow, low-gradient, low LVEF)	Lack of contractile reserve
Exercise echocardiography (ergometric bicycle) - any severe AS	Increase in transvalvular pressure gradient by > 20 mmHg during exercise
	Inducible pulmonary hypertension during exercise (systolic pulmonary pressure ≥ 60 mmHg)
Documentation of valvular calcification	Presence of severe valvular calcifications: Qualitatively (radiology, conventional echocardiography); quantitatively (computed tomography): Calcium score ≥ 1651 Agatston units (lower in women vs men)

LVEF: Left ventricular ejection fraction; AS: Aortic stenosis; AVA: Aortic valve area.