Comorbidity in patients with asymptomatic AS

Abstract

In response to our Perspectives article (Vaishnava, P., Fuster, V., Goldman, M. & Bonow, R. O. Surgery for asymptomatic degenerative aortic and mitral valve disease. Nat. Rev. Cardiol. 8, 173–177 [2011])1 on asymptomatic valve disease, Gilmanov et al. (Gilmanov, D., Mazzone, A., Berti, S. & Glauber, M. Is comorbidity equivalent to symptoms in asymptomatic AS? Nat. Rev. Cardiol. doi:10.1038/nrcardio.2011.203-c1)2 correctly note the often insidious and not easily recognized onset of symptoms in aortic stenosis (AS). We agree that subtle and nonspecific symptoms might not be fully acknowledged by patients, or become falsely attributed to the effects of aging, deconditioning, or comorbidities. Gilmanov et al. also suggest that the “extent of comorbidity” could be considered a “symptom equivalent for prognostic stratification.” Although we agree that comorbidities are common in patients with severe AS, we would caution against this approach of ascribing symptom equivalency to a heterogeneous group of coexisting illnesses. Rather, we would advocate exercise testing with or without echocardiography to risk-stratify asymptomatic patients with AS, by unmasking symptoms and abnormal hemodynamic responses.3, 4, 5