https://orcid.org/0000-0003-3506-6862
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Maria Dons, Tor Biering-Sørensen, Left atrial and ventricular strain: unlocking prognostic insights in moderate aortic stenosis, European Heart Journal - Cardiovascular Imaging, Volume 26, Issue 1, January 2025, Pages 104–106, https://doi.org/10.1093/ehjci/jeae290
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This editorial refers to ‘Incremental prognostic value of left ventricular and left atrial strain in moderate aortic stenosis’, by H.-J. Lee et al., https://doi.org/10.1093/ehjci/jeae285.
Over the past decades, advancements in the treatment of aortic stenosis (AS) with aortic valve replacement (AVR) have challenged the notion that the potential benefits of AVR in non-severe AS are outweighed by procedural risks.1 However, despite these significant advancements, event-free survival in patients with moderate AS has remained unchanged, and some reports suggest survival rates in some cases are comparable with those with severe AS.2
This raises concerns about whether moderate AS should still be considered a benign diagnosis, as morbidity and mortality remain elevated in this otherwise rather heterogeneous patient group. Contributing factors include the misclassification of severe AS as moderate, as well as coexisting cardiovascular conditions such as hypertension, diabetes, hyperlipidaemia, coronary heart disease (CHD), and kidney disease.1 Additionally, structural and functional myocardial changes that arise with LV pressure overload—some of which may be irreversible—are increasingly recognized as risk factors for poor outcomes in moderate AS.3 Current guidelines recommend intervention in moderate AS for patients who are undergoing open heart surgery for other reasons.4 To this date, medical therapy for moderate AS is limited to standard treatment of concomitant heart failure (HF) and CHD. Although hyperlipidaemia is a well-established contributor to AS progression, multiple randomized clinical trials have failed to demonstrate a reduction in AS progression or adverse outcomes with lipid-lowering therapy.5 Lipoprotein(a)-lowering therapy has shown a reduced incidence of AS events compared with placebo6; however, the optimal timing for AVR remains the key contemporary challenge. Given the highly variable progression rate of AS among individuals,3 there is a growing need for improved, personalized risk stratification tools to better identify patients who could benefit from earlier intervention.
