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Cardiology professional societies combined forces to issue the first appropriate use criteria (AUC) for the treatment of patients with severe aortic stenosis.

The document outlining 95 common clinical scenarios and the treatments deemed "rarely appropriate," "may be appropriate," or "appropriate" appeared online in the and flagship journals of certain other of the 11 collaborating societies.

Treatments addressed included transcatheter aortic valve replacement (TAVR), surgical aortic valve replacement (SAVR), and balloon aortic valvuloplasty as a bridge to valve replacement or to palliative care; but the AUC also considered when no intervention is best.

Intervention was deemed generally appropriate in symptomatic patients, though in "scenarios in which expected survival is less than one year and overall health status is influenced more by comorbidities than aortic stenosis, a less aggressive option (medical management) is considered Appropriate."

"In scenarios in which the patient has reduced ejection fraction, intervention is generally considered 'appropriate,' with the decision for TAVR or SAVR based predominantly on surgical risk," the AUC stated, "the only exceptions being situations in which stress test results suggest that the stenosis is pseudosevere rather than severe or in which LV systolic function is profoundly impaired without contractile reserve. In these patients, medical management is considered 'appropriate.'

"In the asymptomatic patient, a positive stress test effectively identifies the patient as symptomatic, with intervention again considered 'appropriate' regardless of surgical risk. In asymptomatic patients with findings suggesting likelihood of symptom onset but not sudden death, intervention is rated 'appropriate,' whereas medical management is considered 'may be appropriate.'"

Writing group chair Robert Bonow, MD, of Northwestern University Feinberg School of Medicine in Chicago, and colleagues emphasized that the scenarios presented were at the "extremes of comorbidity as black and white examples" and acknowledged that real-life patients usually "present in shades of gray."

"There needs to be flexibility in interpreting the nuances of many of these scenarios, just as there needs to be sound clinical judgment in making treatment decisions given the increasing complexity of patients with aortic stenosis," the authors emphasized. "The writing group recognizes that this field is evolving very rapidly, and hence this document will need to be updated in a timely manner in order to reflect advances in technology and clinical outcomes."

Societies that signed on to the AUC were the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons.

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