A 58-year-old asymptomatic man has severe aortic stenosis. Echo shows AVA 0.75 cm², mean gradient 52 mmHg, LVEF 62%, no LV dilation. Per ACC/AHA 2021 VHD guidelines, valve replacement (AVR/TAVR) is indicated when:
- A Symptoms develop — exertional syncope, angina, or dyspnea (onset of Class I indication) ✓
- B Mean gradient exceeds 40 mmHg regardless of symptoms
- C LVEF drops below 50%, even without symptoms
- D AVA <1.0 cm² regardless of symptoms or LVEF
Correct answer: A. Symptoms develop — exertional syncope, angina, or dyspnea (onset of Class I indication)
Explanation
Per 2021 ACC/AHA guidelines, aortic valve replacement (Class I) is indicated for severe AS (AVA ≤1.0 cm², mean gradient ≥40 mmHg) when symptoms develop (exertional angina, syncope, or heart failure — the classic Heyd triad). In truly asymptomatic severe AS with preserved LVEF (≥50%), watchful waiting with serial echo is appropriate. Class IIa indications include LVEF <55% in asymptomatic severe AS, or exercise testing showing symptoms/abnormal BP response. This patient remains asymptomatic with preserved LVEF, so intervention awaits symptoms.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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