Indications and Selection for Aortic Valve Replacement in Severe Aortic Stenosis with Angina and Normal Coronaries

Indication for Valve Replacement

• The presence of angina in patients with severe aortic stenosis constitutes a Class I indication for aortic valve replacement according to the ESC/EACTS (2021) and ACC/AHA (2020) guidelines, with Level B evidence. 1
• Angina is recognized as one of the three cardinal symptoms (angina, dyspnea/heart‑failure, syncope) that mandate immediate valve intervention in severe aortic stenosis. 1

Selection of Replacement Modality

• Age‑based recommendations (ESC/EACTS 2021):

• Surgical‑risk–based recommendations (ESC/EACTS 2021):

Pre‑intervention Evaluation

• Prior to valve replacement, the following assessments are required:

Practical Management Algorithm

• Step 1: Confirm severe, symptomatic aortic stenosis with angina as the presenting symptom. 1
• Step 2: Exclude obstructive coronary artery disease (already done by angiography). 1
• Step 3: Stratify surgical risk using STS‑PROM and record patient age. 1
• Step 4: Choose the replacement modality according to the age‑ and risk‑based criteria above. 1
• Step 5: Proceed with the selected valve replacement without delay, because angina signifies symptomatic disease. 1
• Step 6: Avoid conventional anti‑anginal medications (e.g., nitrates, beta‑blockers) as definitive therapy; they may be used only as a temporary bridge. 1