HomeCirculationVol. 136, No. 19Letter by Tzanis et al Regarding Article, “Stress Testing in Asymptomatic Aortic Stenosis” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Tzanis et al Regarding Article, “Stress Testing in Asymptomatic Aortic Stenosis” Georgios Tzanis, MD, PhD, Christos Charitos, MD and Serafim Nanas, MD, PhD Georgios TzanisGeorgios Tzanis From Cardiopulmonary Exercise Testing and Rehabilitation Laboratory (G.T., S.N.), Department of Cardiac Surgery (C.C.), Evaggelismos Hospital, Athens, Greece. Search for more papers by this author , Christos CharitosChristos Charitos From Cardiopulmonary Exercise Testing and Rehabilitation Laboratory (G.T., S.N.), Department of Cardiac Surgery (C.C.), Evaggelismos Hospital, Athens, Greece. Search for more papers by this author and Serafim NanasSerafim Nanas From Cardiopulmonary Exercise Testing and Rehabilitation Laboratory (G.T., S.N.), Department of Cardiac Surgery (C.C.), Evaggelismos Hospital, Athens, Greece. Search for more papers by this author Originally published7 Nov 2017https://doi.org/10.1161/CIRCULATIONAHA.117.029575Circulation. 2017;136:1866–1867To the Editor:We read with great interest the state-of-the-art review by Redfors et al1 regarding the emerging role of stress testing in the field of asymptomatic aortic stenosis (AS) management. With this letter, we would like to highlight the role of cardiopulmonary exercise test (CPET) in the evaluation of symptoms and disease prognosis of asymptomatic AS. Insights from cardiopulmonary exercise tests could possibly answer how symptomatic asymptomatic AS could be.Five decades ago, Ross and Braunwald2 described the importance of symptom estimation in AS, stating, “Once symptoms develop, the average course is short.” Since then, little has changed in the management of severe AS. We know we have to intervene when symptoms develop, but little is known about how to evaluate the symptoms and the (a)symptomatic patient.CPET is the gold standard for estimating symptoms, objective assessing functional capacity, evaluating the origin of the symptoms (cardiac/pulmonary), and obtaining prognostic information for a series of diseases, especially heart failure where CPET indices are closely associated with morbidity and survival.Related to this concept, a recent study by Domanski et al3 showed that a significant proportion of patients with asymptomatic AS have really low peak oxygen consumption due to cardiac limitation, as assessed by CPET, possibly indicating high incidence of false “asymptomatic”. CPET, unlike the AS severity criteria derived from rest and supine exercise echocardiography, predicted a poor event free survival. Levy et al4 also suggested that CPET could accurately detect false asymptomatic patients with AS and patients likely to develop symptoms. CPET parameters (peak oxygen consumption and ventilation-carbon dioxide production slope) that provide prognostic information and are strongly linked with survival in heart failure were both predictors of an abnormal exercise test and the development of cardiac symptoms related to AS (dyspnea, syncope, or angina), both representing triggers for surgery with current practice.Another important study by Dhole et al5 evaluated the prognostic role of CPET in AS. Authors found that exercise capacity was significantly reduced in patients with moderate/severe AS, and that peak oxygen consumption was independently associated with survival in these groups of patients, whereas the self-estimation of equivocal symptoms was not associated with increased mortality or aortic valve replacement compared with the patients who were asymptomatic.Severe AS is not a black-and-white scenario but a continuum. AS is a chronic, slow-developing disease where patients sometimes adapt by decreasing their level of activity or even underestimate their condition (false asymptomatic), while symptoms and reduced exercise capacity may be of noncardiac origin (false symptomatic). With the progression of the disease, symptoms can be debilitating for activities of daily living, and usually only then are patients sent for surgery. The whole concept could be not just categorizing patients as asymptomatic/symptomatic but objectively assessing the functional capacity and subjective nature of symptoms by CPET. It is important to note that CPET might also be used to obtain information for the prognosis, as in other disease states such as heart failure.Further studies implementing CPET should estimate the optimal prognostic parameters that would consequently elucidate the optimal timing for intervention in AS.Georgios Tzanis, MD, PhDChristos Charitos, MDSerafim Nanas, MD, PhDDisclosuresNone.FootnotesCirculation is available at http://circ.ahajournals.org.
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