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Introduction
Aortic valve disease is commonly encountered in the clinical assessment of elderly patients. Until the middle of the 20th century many cases were due to inflammatory, mostly post-rheumatic, valve damage and the burden of disease fell on the young and middle-aged. However, despite the decline of rheumatic fever in most parts of the world, the prevalence of aortic valve disease is rising. This is due to the increase in mean life expectancy to unprecedented levels in many countries, which has enabled a large number of people to live long enough to develop degenerative-calcific aortic valve damage in late life. Patients with bicuspid aortic valves also tend to progress to significant aortic stenosis. Consequently, aortic stenosis (AS) is now mainly a disease of old age.1-4
Until recently, the range of treatment options for moderate to severe AS was limited in old age, particularly for the very old and those with significant co-morbidities that rendered them unfit for the rigours of major cardiac surgery. Further, the evidence for benefit from aortic valve replacement (AVR) in very elderly patients had not, until recently, been confidently established. This generated a very conservative approach to the management of symptomatic AS among general practitioners, geriatricians and cardiologists, particularly for patients above the age of 80 years, and a rate of referral for AVR that was probably too low. However, over the last 15 years there has been a great improvement in the quality of evidence for benefit from several interventions for AS, and the arrival of new technologies has widened the range of options for treatment in old age. This review sets out to examine that evidence, with particular reference to outcomes in older patients, and to frame the subject in the context of new insights into the epidemiology and pathology of aortic valve disease.
Search methods
We used the terms 'aortic stenosis', 'aortic valve disease', 'elderly', 'older adults', 'old age' and 'aortic valve replacement' to search PubMed, Medline, Exerpta Medica and Ovid from 1990 to 2010. Ninety-four articles were identified for initial screening. Further selection was made according to the quality of the research, including methodology and sampling for trials, and large size for series and case ascertainment studies. Forty-nine...