Toward the Earlier Treatment of Aortic Stenosis: What’s the Evidence?

Aortic stenosis (AS) is the most common valvular disease worldwide and is associated with substantial morbidity and mortality if left untreated. Traditionally, intervention has been reserved for patients with severe, symptomatic disease, with limited exceptions for asymptomatic individuals demonstrating hemodynamic compromise such as reduced ejection fraction, markedly elevated B-type natriuretic peptide (BNP), or very severe AS. This paradigm, however, is increasingly being questioned. Emerging evidence shows that by the time symptoms develop, many patients have already sustained structural cardiac changes—both adaptive and maladaptive—that may not fully regress after relief of the valvular obstruction. Consequently, in waiting for symptoms, a critical therapeutic window may be missed. Advances in echocardiography and cardiac magnetic resonance (cMRI) have improved our ability to detect early markers of cardiac injury, potentially allowing for more precise risk stratification. This has prompted the question of whether earlier intervention before significant cardiac damage has occurred could improve clinical outcomes compared to a symptom-based approach to timing. In this review, we examine the evolving evidence supporting a shift toward earlier intervention in AS, with particular attention to the role of cardiac injury as a determinant of prognosis and treatment timing.