• Andrea Sonaglioni, Michele Lombardo, Massimo Baravelli, Graziana Trotta, Carmen Sommese, and Claudio Anzà.
• Department of Cardiology, Ospedale San Giuseppe Multimedica, Via San Vittore 12, 20123, Milan, Italy. sonaglioniandrea@gmail.com.
• Int J Cardiovasc Imaging. 2015 Dec 1; 31 (8): 1519-27.

BackgroundPatients with mild to moderate aortic stenosis (AS) seem to have a worse outcome than commonly expected. Early identification of subjects who may develop a rapid disease progression or cardiovascular events is critical in order to apply adequate risk management.Study DesignObservational prospective single-centre study.ObjectiveTo determine the prognostic role of exercise stress echocardiography (ESE) in patients with mild and moderate asymptomatic AS.PatientsNinety consecutive patients (mean age 74 ± 12 years) with isolated mild and moderate AS were enrolled into the study protocol over a 20 months period. Follow-up time was 12 months.MethodsA complete echocardiographic study with tissue Doppler imaging (TDI) was performed at baseline and during semi-supine symptom-limited exercise test to evaluate: (1) the occurrence of symptoms, (2) ST segment changes, (3) transaortic pressure gradient, (4) the E/A ratio, (5) the E/e' ratio and (6) the systolic pulmonary artery pressure.Main Outcome MeasuresDuring the 1 year follow-up time, we evaluated the occurrence of adverse cardiac events, defined as any of the following: (1) cardio-vascular hospitalization; (2) requirement for aortic valve replacement; (3) cardiac death.ResultsDuring follow-up, three patients died, 11 underwent aortic valve replacement and 26 had cardiovascular hospitalizations. On univariate analysis, patients who exhibited symptoms during exercise (HR 2.93, p = 0.003); the occurrence of a ≥ 2 mm exercise-induced ST segment depression (HR 3.12, p = 0.001); a ≥ 15 mmHg increase in mean transaortic pressure gradient during exercise (HR 2.77, p = 0.001); a ≥ 50 mmHg exercise-induced increase in systolic pulmonary artery pressure (HR 2.90, p = 0.009); an exercise-induced pseudo-normalization of the E/A ratio (E/A ≥ 1) (HR 7.50, p = 0.0001) and, particularly, a ≥ 15 exercise-induced increase in the E/e' ratio (HR 7.69, p = 0.0001) had a significantly higher risk of cardiac events during the follow-up time. On multivariate analysis, only the latter covariate (HR 6.04, p = 0.009) was independently associated with adverse cardiac events.ConclusionsA ≥ 15 stress-induced increase in E/e' ratio is highly predictive of cardiac events in patients with mild to moderate AS. Assessment of diastolic function using TDI during ESE provides additional prognostic information in such patients.

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