title: Meta-analysis of the impact of intervention versus symptom-driven management in asymptomatic severe aortic stenosis.
abstract: The management of patients with asymptomatic, severe aortic stenosis (AS) is controversial. We performed a meta-analysis to examine the impact on outcomes of aortic valve replacement (AVR) in patients with severe asymptomatic AS versus a symptom-driven intervention approach.
  
  
  
  A search for studies that examined the outcomes of AVR and management of asymptomatic severe AS was performed. We examined the end points of all-cause mortality, cardiac mortality and sudden cardiac death. Our analysis compared early AVR in asymptomatic patients with a symptom-driven AVR approach (excluding symptomatic patients who did not undergo AVR).
  
  
  
  Four observational studies were identified with a total of 1300 patients. There was significant heterogeneity between studies (I2=72%). Using a random-effects model, there was a trend towards reduced overall mortality in patients undergoing early AVR compared with a symptom-driven AVR approach (OR 0.54, 95% CI 0.26 to 1.12, p=0.1). There was no significant reduction in cardiac mortality or sudden death (OR 0.78, p=0.85, and OR 0.34, p=0.25, respectively).
  
  
  
  Although there was a trend towards reduced overall mortality when comparing early AVR in patients with asymptomatic, severe AS to a symptom-driven AVR approach, there was no significant difference in cardiac mortality or sudden death. An individual approach focusing on individual risk stratification and operative mortality is required until more robust, randomised trial data are available.
authors.affiliation: Echocardiography Laboratory, Barts Heart Centre, St Bartholomew's Hospital, London, UK.
authors.forename: Wei Yao
authors.initials: WY
authors.lastname: Lim
authors.affiliation: Echocardiography Laboratory, Barts Heart Centre, St Bartholomew's Hospital, London, UK.
authors.forename: Anantharaman
authors.initials: A
authors.lastname: Ramasamy
authors.affiliation: Echocardiography Laboratory, Barts Heart Centre, St Bartholomew's Hospital, London, UK.|Valvular Heart Disease Clinic, Barts Heart Centre, St Bartholomew's Hospital, London, UK.|Institute of Cardiovascular Science, University College London, London, UK.
authors.forename: Guy
authors.initials: G
authors.lastname: Lloyd
authors.affiliation: Echocardiography Laboratory, Barts Heart Centre, St Bartholomew's Hospital, London, UK.|Valvular Heart Disease Clinic, Barts Heart Centre, St Bartholomew's Hospital, London, UK.|Institute of Cardiovascular Science, University College London, London, UK.
authors.forename: Sanjeev
authors.initials: S
authors.lastname: Bhattacharyya
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D058070:Asymptomatic Diseases; D016009:Chi-Square Distribution; D016757:Death, Sudden, Cardiac / Q000209:etiology / Q000517:prevention & control*; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome