Early Intervention Versus Clinical Surveillance in Asymptomatic Severe Aortic Stenosis: An Evidence-Based Update

Degenerative aortic stenosis (AS) is the most common valvular heart disease in developed countries, particularly in individuals over 65 years of age. While the indication for aortic valve replacement in the presence of symptoms is well established, the optimal management of patients with severe asymptomatic AS remains controversial. This review integrates the epidemiology and pathophysiology of AS, the contribution of echocardiography and other diagnostic modalities (computed tomography, cardiac magnetic resonance, biomarkers), and summarizes contemporary evidence comparing early intervention versus clinical surveillance. Advanced parameters such as global longitudinal strain, mechanical dispersion, myocardial work, Global work index, as well as structural and functional cardiac damage staging systems, are highlighted. Collectively, randomized controlled trials from RECOVERY, AVATAR, EVOLVED, and EARLY transcatheter aortic valve replacement trials, complemented by registries such as CURRENT AS and observational analyses suggest that early intervention strategy reduces the risk of heart failure-related hospitalizations and cerebrovascular events in asymptomatic severe AS, while the impact on all-cause mortality remains less consistent across studies. Identifying the optimal time window for intervention before irreversible myocardial damage occurs, and refining patient selection using advanced imaging modalities, remain key priorities for both clinical practice and research. Current evidence indicates that, although watchful waiting continues to be appropriate in carefully selected patients, early intervention is gaining stronger support, particularly in those with adverse prognostic markers or in settings where close surveillance is not feasible.