ESC / EACTS · 2025

Aortic Stenosis — Management Guideline

Source: 2025 ESC/EACTS Guidelines for the management of valvular heart disease, European Heart Journal

✓ Edition checked 3 Oct 2026 — ESC / EACTS 2025 is the current edition as of this date.

Guideline: Strong Guideline: Conditional Guideline: Not recommended ClinicoQ pathway suggestion (not from the cited guideline)

Diagnosis

Diagnostic criteria Severe aortic stenosis is diagnosed by echocardiography using peak transvalvular velocity, mean pressure gradient, and aortic valve area, typically with a peak velocity of 4.0 m/s or above, mean gradient 40 mmHg or above, or valve area 1.0 cm2 or below (general clinical knowledge, consistent with prior ESC guidance, not verified in the 2025 text). Discordant measurements (for example low-flow states or preserved ejection fraction) need the integrated approach described below, including CT calcium scoring. Cardinal symptoms are exertional dyspnoea, angina, and syncope.

⚠ Alarm features (investigate before diagnosing)

Syncope or presyncope on exertion
Angina
Heart failure symptoms or cardiogenic shock
Rapid progression of valve gradient or velocity on serial echocardiography

Initial workup

Test	When to order
Transthoracic echocardiography (Vmax, mean gradient, aortic valve area, LVEF)	Initial diagnosis and follow-up of suspected aortic stenosis.
Integrated assessment for discordant severity	Confirm valve area criteria, exclude measurement error, use flow status and LVEF, add dobutamine stress echocardiography when appropriate, and use CT aortic valve calcium scoring with sex-specific thresholds.
CT to exclude coronary artery disease	First-line test before valvular intervention.
Heart Valve Team review	For every patient considered for valve intervention, to weigh anatomy, procedural risk, lifetime strategy, and patient preference.

Decision Points

❓ Does the patient with severe aortic stenosis have symptoms?

Yes, symptomatic severe aortic stenosis → Symptomatic severe aortic stenosis

No symptoms, severe high-gradient AS with LVEF 50% or above → Asymptomatic severe high-gradient aortic stenosis with preserved LVEF

❓ For a patient who needs valve replacement, what is the age and anatomy?

Age 70 years or older with a tricuspid aortic valve and suitable anatomy → TAVI (patients aged 70 years or older with tricuspid aortic valve and suitable anatomy)

Under 70 years at low surgical risk, or anatomy unsuitable for TAVI → SAVR (patients under 70 years at low surgical risk, or anatomy unsuitable for TAVI)

Treatment

Symptomatic severe aortic stenosis

1 Aortic valve intervention after Heart Valve Team review Strong (Guideline recommendation) — Class I, level B in symptomatic severe high-gradient aortic stenosis, regardless of LVEF

Dose: —
Duration: Timely, once severe symptomatic stenosis is confirmed
Evidence level: High
Avoid if: Limited life expectancy or futility judged by the Heart Valve Team
If no response ClinicoQ pathway: Choose TAVI or SAVR by age, anatomy, and surgical risk

2 TAVI (patients aged 70 years or older with tricuspid aortic valve and suitable anatomy) Strong (Guideline recommendation) — Class I, level A in patients aged 70 years or older with a tricuspid aortic valve and suitable anatomy; the age cut-off was lowered from 75 to 70 years in 2025

Dose: —
Duration: Procedure
Evidence level: High
Avoid if: Anatomy unsuitable for TAVI (for example coronary obstruction risk); bicuspid or complex anatomy needs team judgment

3 SAVR (patients under 70 years at low surgical risk, or anatomy unsuitable for TAVI) Strong (Guideline recommendation) — Class I, level A: SAVR is recommended in patients under 70 years at low surgical risk

Dose: —
Duration: Procedure
Evidence level: High
Avoid if: Prohibitive surgical risk

Asymptomatic severe high-gradient aortic stenosis with preserved LVEF

1 Aortic valve intervention for LV systolic dysfunction Strong (Guideline recommendation) — Class I in asymptomatic severe aortic stenosis with LVEF below 50% and no other cause (the level of evidence differs between the summaries seen)

Dose: LVEF below 50% with no other cause
Duration: Timely
Evidence level: High
Avoid if: High procedural risk judged by the Heart Team

2 Early aortic valve intervention as an alternative to close surveillance Guideline recommendation (Class IIa, level A) — should be considered when the procedural risk is low; also preferred when close surveillance is not feasible

Dose: Severe high-gradient stenosis with LVEF 50% or above, confirmed asymptomatic by a normal exercise test when feasible
Duration: Elective
Evidence level: High
Avoid if: High procedural risk
If no response: If not intervening, continue regular clinical and echocardiographic surveillance

3 Early intervention when adverse features are present Guideline recommendation (Class IIa, level B) — should be considered when the procedural risk is low

Dose: LVEF 50% or above plus at least one of: peak velocity above 5 m/s or mean gradient 60 mmHg or above; severe valve calcification with peak velocity rising 0.3 m/s or more per year; BNP or NT-proBNP more than 3 times normal, confirmed on repeat; LVEF below 55% with no other cause
Duration: Elective
Evidence level: Moderate
Avoid if: High procedural risk

⚠️ This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.