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Answer 3
  1. Repeat clinical assessment in 3 to 6 months and repeat echocardiographic assessment within 1 year or sooner if symptoms develop. Even with severe aortic stenosis, asymptomatic patients enjoy a natural history similar to normal patients until the development of symptoms.3 These patients are best monitored by serial clinical assessment with a thorough evaluation for exertional symptoms, as well as annual echocardiogram for development of LV systolic dysfunction. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines suggest serial echocardiography annually for severe aortic stenosis (or with change in clinical status, especially development of dyspnea, angina, or syncope) every 1 to 2 years for moderate stenosis and every 3 to 5 years for mild stenosis.3 Given this patient’s absence of symptoms and reassuring physical examination, there is no role for hospitalization at this time. Exercise testing in asymptomatic severe aortic stenosis is controversial and may be helpful in some patients with nonspecific symptoms to assess exercise capacity, development of exertional symptoms, or abnormal hemodynamic response to exercise. Stress testing in asymptomatic patients with severe aortic stenosis carries risk and is ideally performed with direct communication with the testing facility staff and cardiology consultation. Exercise stress testing is unlikely to be useful for the assessment of coronary artery disease in the setting of severe aortic stenosis. Exercise stress testing is contraindicated in patients with symptomatic aortic stenosis.
    Since volume overload or history of heart failure was not demonstrated, there is no role for diuresis in this patient. Statin therapy has not been demonstrated to alter the course of severe calcific aortic stenosis and should not be initiated for this purpose. Cardiology consultation in the future would be warranted when aortic valve replacement is contemplated and preoperative cardiac catheterization is needed, which is routinely performed prior to surgical valve replacement for evaluation of coronary artery disease.

    3. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). J Am Coll Cardiol 2008;52(13):el–142.

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