Management of coronary artery disease in patients with aortic stenosis

• Published in: Heart (British Cardiac Society) Vol. 109; no. 4; pp. 322 - 329
• Main Authors: Androshchuk, Vitaliy, Patterson, Tiffany, Redwood, Simon R
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group Ltd and British Cardiovascular Society 01.02.2023; BMJ Publishing Group LTD
• Subjects: Adenosine; Aged; Angina pectoris; Aortic stenosis; Aortic Valve - surgery; Aortic Valve Stenosis; Aortic Valve Stenosis - complications; Aortic Valve Stenosis - diagnosis; Aortic Valve Stenosis - surgery; Cardiovascular disease; Clinical outcomes; Coronary Angiography; Coronary Artery Disease; Coronary Artery Disease - diagnosis; Coronary Artery Disease - diagnostic imaging; Coronary vessels; Education in Heart; Heart Valve Prosthesis Implantation; Heart Valve Prosthesis Implantation - adverse effects; Hemodynamics; Humans; Intervention; Ischemia; Medical imaging; Percutaneous Coronary Intervention; Risk Factors; Transcatheter Aortic Valve Replacement; Transcatheter Aortic Valve Replacement - adverse effects; Treatment Outcome; Vein & artery diseases; United Kingdom > UK; Transcatheter Aortic Valve Replacement; Heart Valve Prosthesis Implantation; Coronary Artery Disease; Percutaneous Coronary Intervention; Aortic Valve Stenosis
• ISSN: 1355-6037; 1468-201X
• DOI: 10.1136/heartjnl-2022-321605

Aortic stenosis (AS) is the most common valvular heart disorder in the elderly population. As a result of the shared pathophysiological processes, AS frequently coexists with coronary artery disease (CAD). These patients have traditionally been managed through surgical aortic valve replacement (SAVR) and coronary artery bypass grafting. However, increasing body of evidence supports transcatheter aortic valve implantation (TAVI) as an alternative treatment for severe AS across the spectrum of operative risk. This has created the potential for treating AS and concurrent CAD completely percutaneously. In this review we consider the evidence guiding the optimal management of patients with severe AS and CAD. While invasive coronary angiography plays a central role in detecting CAD in patients with AS undergoing surgery or TAVI, the benefits of complementary functional assessment of coronary stenosis in the context of AS have not been fully established. Although the indications for revascularisation of significant proximal CAD in SAVR patients have not recently changed, routine revascularisation of all significant CAD before TAVI in patients with minimal angina is not supported by the latest evidence. Several ongoing trials will provide new insights into physiology-guided revascularisation in TAVI recipients. The role of the heart team remains essential in this complex patient group, and if revascularisation is being considered careful evaluation of clinical, anatomical and procedural factors is essential for individualised decision-making.