Comparative Efficacy of Early Intervention versus Conservative Management in Asymptomatic Severe Aortic Stenosis: A Systematic Review and Meta-analysis

Abstract

Objectives: This systematic review and meta-analysis aimed to evaluate the comparative efficacy of early valve intervention versus conservative management in patients with asymptomatic severe aortic stenosis (AS), with a particular focus on mortality and major cardiovascular outcomes. Methods: Following PRISMA guidelines, a comprehensive search was conducted in PubMed, Scopus, Web of Science, and the Cochrane Library up to March 2024. Eligible studies included randomized controlled trials (RCTs) and observational studies comparing early surgical or transcatheter aortic valve replacement (SAVR or TAVR) with conservative (watchful waiting) management. The primary outcome was all-cause mortality, while secondary outcomes included cardiovascular and non-cardiovascular mortality, major adverse cardiovascular events (MACEs), myocardial infarction, sudden cardiac death, heart failure hospitalization, and stroke. Results: Fourteen studies with a total of 7,775 patients (2 RCTs and 12 observational studies) were included. Pooled analyses demonstrated that early intervention significantly reduced all-cause mortality (RR 0.40; 95% CI 0.32–0.51), cardiac mortality (RR 0.40; 95% CI 0.26–0.62), and non-cardiac mortality (RR 0.39; 95% CI 0.31–0.49). Similarly, early intervention was associated with lower risks of MACEs, myocardial infarction, sudden cardiac death, and heart failure hospitalization, without a significant increase in stroke risk. Certainty of evidence, however, was rated as low to very low due to heterogeneity and reliance on observational studies. Conclusions: Early intervention in asymptomatic severe AS may reduce mortality and major cardiovascular events compared to conservative management.