Management of asymptomatic severe aortic stenosis: a systematic review and meta-analysis of randomized controlled trials.

Introduction: Whilst aortic stenosis remains the most prevalent valvular abnormality, the management of asymptomatic severe aortic stenosis remains a clinical challenge. Recently, two randomised-controlled trials (RCTs) - EVOLVED (Early Intervention in Patients With Asymptomatic Severe Aortic Stenosis and Myocardial Fibrosis) and Early TAVR (Transcatheter Aortic-Valve Replacement for Asymptomatic Severe Aortic Stenosis) - have been published, alongside an extended follow-up from the AVATAR (Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis) study.

Evidence acquisition: In response, we conducted a systematic review of PubMed, Ovid, and Cochrane databases, identifying RCTs up to October 29, 2024, that compared early intervention with conventional management.

Evidence synthesis: Four studies met the inclusion criteria, with a combined total of 1427 patients across the trials. Meta-analysis of the primary endpoints across these studies demonstrated a benefit with early intervention (HR=0.50, 95% CI: 0.35-0.73). However, we did not find mortality and cardiac mortality to show significant reductions (HR=0.68, 95% CI: 0.40-1.18 and HR=0.66, 95% CI: 0.33-1.29, respectively). Crucially, stroke outcomes were improved with early intervention (HR=0.60, 95% CI: 0.38-0.95), as were unplanned hospitalizations (HR=0.40, 95% CI: 0.30-0.53).

Conclusions: These findings confirm the safety of early intervention and suggest a reduction in stroke incidence, although no significant benefits were observed in overall or cardiac mortality; results which can help to guide shared decision-making with patients and prevent adverse health outcomes.