Exercise stress echocardiography parameters, including a mean transvalvular gradient increase ≥18-20 mmHg, peak E/e' ≥15, and systolic pulmonary artery pressure ≥60 mmHg, predicted adverse outcomes.
Systematic Review
Does exercise stress echocardiography provide prognostic value for predicting adverse events in adult patients with asymptomatic moderate or severe aortic stenosis?
Exercise stress echocardiography provides incremental prognostic value in asymptomatic moderate and severe aortic stenosis by identifying high-risk stress-derived hemodynamic thresholds.
Background: Risk stratification of patients with asymptomatic aortic stenosis (AS) remains challenging, as symptom-based assessment may underestimate disease severity. Exercise stress echocardiography (ESE) provides a comprehensive evaluation of valvular, ventricular, and cardiopulmonary responses under physiological stress and may improve prognostic assessment. Methods: A systematic review was conducted according to PRISMA guidelines to evaluate the prognostic value of ESE in asymptomatic moderate and severe AS. Electronic databases (PubMed, Scopus, and EMBASE) were searched from inception to March 2026. Studies were included if they assessed adult patients with asymptomatic moderate or severe AS undergoing exercise-based stress echocardiography and reported clinical outcomes. Studies using exclusively pharmacological stress or lacking outcome data were excluded. Data were extracted and synthesized qualitatively. Continuous variables were summarized as weighted medians and interquartile ranges. Results: A total of 11 studies were included, encompassing a heterogeneous population of patients with moderate-to-severe and severe AS. During follow-up, a substantial proportion of patients experienced adverse events, including symptom onset, aortic valve replacement, or death. Across studies, exercise-derived parameters consistently showed strong prognostic value. In particular, exercise-induced increases in mean transvalvular gradient, an elevated E/e’ ratio, the development of pulmonary hypertension, and reduced functional capacity emerged as the most reproducible predictors of adverse outcomes. Notably, thresholds such as an increase in mean transvalvular gradient ≥ 18–20 mmHg, peak exercise E/e’ ≥ 15, and systolic pulmonary artery pressure ≥ 60 mmHg were consistently associated with a higher risk across multiple studies. Myocardial deformation parameters and biomarkers such as exercise-induced BNP further contributed to risk stratification in selected studies. In contrast, resting parameters alone were less consistently predictive. Conclusions: ESE provides incremental prognostic information in asymptomatic moderate and severe AS by unmasking subclinical hemodynamic and myocardial abnormalities. The integration of stress-derived parameters, including reproducible threshold values, into clinical assessment may improve risk stratification and support more individualized management strategies. Further studies are needed to validate these cut-offs and define their role in guiding clinical decision-making.
Sonaglioni et al. (Fri,) conducted a systematic review in Asymptomatic moderate and severe aortic stenosis. Exercise stress echocardiography vs. Resting parameters was evaluated on Adverse events (symptom onset, aortic valve replacement, or death). Exercise stress echocardiography parameters, including a mean transvalvular gradient increase ≥18-20 mmHg, peak E/e' ≥15, and systolic pulmonary artery pressure ≥60 mmHg, predicted adverse outcomes.
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