Acute decompensated aortic stenosis: the final common pathway of a failing system

The theoretical paradigm for management of aortic stenosis (AS) assumes an early diagnosis, with surveillance until symptoms develop, followed by an elective intervention. In current practice, however, acute decompensation of aortic stenosis (ADAS) leading to hospital admission is commonplace, and one quarter of transcatheter aortic valve implantation (TAVI) procedures performed in the UK are now performed urgently on patients with ADAS. Acute decompensation and hospital admission often reflects a failure of the upstream AS pathway, typically encompassing late diagnosis, delays to work-up, and challenges with delivery of definitive procedural intervention. Patients presenting with ADAS have a higher prevalence of cardiac damage, frailty, and comorbidities, all of which impact long-term outcome. This Viewpoint reviews the current paradigm and its limitations, before considering strategies to reduce the frequency of ADAS, and outlining clinical and research priorities to better understand ADAS, to provide better standardisation of care pathways in ADAS, and to improve outcomes for patients that present with ADAS.