1. No medical therapies influence the natural history of AS.
2. Statins (which demonstrated favorable effects in pre-clinical studies) do not affect disease progression and clinical trials targeting calcium metabolic pathways are ongoing.
3. Patients with HF who are unsuitable (or waiting) for SAVR or TAVI should be medically treated according to ESC heart failure Guidelines. ACEIs are safe in aortic stenosis (provided that blood pressure is monitored carefully) and may have beneficial myocardial effects before the onset of symptoms, and after TAVI and SAVR.
4. Coexisting hypertension should be treated to avoid additional afterload, although medication (particularly vasodilators) should be titrated to avoid symptomatic hypotension.

1. No medical therapies for aortic stenosis can improve outcomes.
2. HF medical treatment should be given to all heart failure patients with symptomatic severe aortic stenosis.
3. Care must be taken using vasodilators to avoid hypotension.
4. Importantly, possible improvement of symptoms after medical therapy should not delay intervention.

1. In patients at risk of developing AS (Stage A) and in patients with asymptomatic AS (Stages B and C), hypertension should be treated according to standard Guideline-Directed Management and Therapy, started at a low dose, and gradually titrated upward as needed, with appropriate clinical monitoring (1, B-NR).
2. In all patients with calcific AS, statin therapy is indicated for primary and secondary prevention of atherosclerosis on the basis of standard risk scores. (1, A).
3. In patients who have undergone TAVI, renin–angiotensin system blocker therapy (ACE inhibitor or ARB) may be considered to reduce the long-term risk of all-cause mortality (2B, B-NR).
4. In patients with calcific AS (Stages B and C), statin therapy is not indicated for prevention of hemodynamic progression of AS (3 [no benefit], A).

Abbreviations: ACC, American College of Cardiology; ACEI, angiotensin-converting enzyme inhibitor; AHA, American Heart Association; ARB, angiotensin receptor blocker; AS, aortic stenosis; EACTS, European Association for Cardio-Thoracic Surgery; ESC, European Society of Cardiology; HF, heart failure; LV, left ventricle; LVEF, left ventricular ejection fraction; SAVR, surgical aortic valve replacement; TAVI, transcatheter aortic valve implantation; VHD, valvular heart disease.

Asymptomatic patients

1. Intervention is recommended in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF <50%) without another cause (class I, B).
2. Intervention is recommended in asymptomatic patients with severe aortic stenosis and demonstrable symptoms on exercise testing (class I, C).
3. Intervention should be considered in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF <55%) without another cause (class IIa, B).
4. Intervention should be considered in asymptomatic patients with severe aortic stenosis and a sustained fall in BP (>20 mmHg) during exercise testing (class IIa, C).
5. Intervention should be considered in asymptomatic patients with LVEF >55% and a normal exercise test if the procedural risk is low and one of the following parameters is present:
   • Very severe aortic stenosis (mean gradient ≥60 mmHg or Vmax >5 m/s).
   • Severe valve calcification (ideally assessed by CCT) and Vmax progression ≥0.3 m/s/year.
   • Markedly elevated BNP levels (>3 x age- and sex-corrected normal range) confirmed by repeated measurements and without other explanation (class IIa, B).

Symptomatic patients

1. Intervention is recommended in symptomatic patients with severe, high-gradient aortic stenosis [mean gradient ≥40 mmHg, peak velocity ≥4.0 m/s, and valve area ≤1.0 cm2 (or ≤0.6 cm²/m²)] (class I, B).
2. Intervention is recommended in symptomatic patients with severe low-flow (SVi ≤35 mL/m2), low-gradient (<40 mmHg) aortic stenosis with reduced ejection fraction (<50%), and evidence of flow (contractile) reserve (class I, B).
3. Intervention should be considered in symptomatic patients with low-flow, low-gradient (<40 mmHg) aortic stenosis with normal ejection fraction after careful confirmation that the aortic stenosis is severed (class IIa, C).
4. Intervention should be considered in symptomatic patients with low-flow, low-gradient severe aortic stenosis and reduced ejection fraction without flow (contractile) reserve, particularly when CCT calcium scoring confirms severe aortic stenosis (class IIa, C).
5. Intervention is not recommended in patients with severe comorbidities when the intervention is unlikely to improve quality of life or prolong survival >1 year. (class III, C).

Mode of intervention

1. Aortic valve interventions must be performed in heart valve centers that declare their local expertise and outcomes data, have active interventional cardiology and cardiac surgical programmes on site, and a structured collaborative heart team approach (class I, level C).
2. The choice between surgical and transcatheter intervention must be based upon careful evaluation of clinical, anatomical, and procedural factors by the heart team, weighing the risks and benefits of each approach for an individual patient. The heart team recommendation should be discussed with the patient who can then make an informed treatment choice (class I, level C).
3. SAVR is recommended in younger patients who are low risk for surgery (<75 years and STS-PROM/ EuroSCORE II <4%), or in patients who are operable and unsuitable for transfemoral TAVI (class I, level B).
4. TAVI is recommended in older patients (≥75 years), or in those who are high risk (STS-PROM/ EuroSCORE IIf >8%) or unsuitable for surgery (class I, level A).
5. SAVR or TAVI are recommended for remaining patients according to individual clinical, anatomical, and procedural characteristics (class I, level B).
6. Non-transfemoral TAVI may be considered in patients who are inoperable and unsuitable for transfemoral TAVI (class IIb, level C).

1. Aortic valve intervention, TAVI or SAVR is recommended in patients with HF and severe high-gradient AS to reduce mortality and improve symptoms (class I).
2. It is recommended that the choice between TAVI and SAVR be made by the heart team, according to individual patient preference and features including age, surgical risk, clinical, anatomical and procedural aspects, weighing the risks and benefits of each approach (class I).

1. For symptomatic and asymptomatic patients with severe AS and any indication for aortic valve replacement who are <65 years of age or have a life expectancy >20 years, SAVR is recommended (1A).
2. For symptomatic patients with severe AS who are 65 to 80 years of age and have no anatomic contraindication to transfemoral TAVI, either SAVR or transfemoral TAVI is recommended after shared decision making about the balance between expected patient longevity and valve durability (1A).
3. For symptomatic patients with severe AS who are >80 years of age or for younger patients with a life expectancy <10 years and no anatomic contraindication to transfemoral TAVI, transfemoral TAVI is recommended in preference to SAVR (1A).
4. In asymptomatic patients with severe AS and an LVEF <50% who are ≤ 80 years of age and have no anatomic contraindication to transfemoral TAVI, the decision between TAVI and SAVR should follow the same recommendations as for symptomatic patients in Recommendations 1, 2, and 3 above (1, B-NR).
5. For asymptomatic patients with severe AS and an abnormal exercise test, very severe AS, rapid progression, or an elevated BNP (COR 2a indications for AVR), SAVR is recommended in preference to TAVI (1, B-NR).
6. For patients with an indication for aortic valve replacement for whom a bioprosthetic valve is preferred but valve or vascular anatomy or other factors are not suitable for transfemoral TAVI, SAVR is recommended (1A).
7. For symptomatic patients of any age with severe AS and a high or prohibitive surgical risk, TAVI is recommended if predicted post-TAVI survival is >12 months with an acceptable QoL (1A).
8. For symptomatic patients with severe AS for whom predicted post-TAVI or post-SAVR survival is <12 months or for whom minimal improvement in QoL is expected, palliative care is recommended after shared decision-making, including discussion of patient preferences and values (1, C-EO).
9. In critically ill patients with severe AS, percutaneous aortic balloon dilation may be considered as a bridge to SAVR or TAVI (2b, C-EO).

Abbreviations: ACC, American College of Cardiology; ACEI, angiotensin-converting enzyme inhibitor; AHA, American Heart Association; ARB, angiotensin receptor blocker; AS, aortic stenosis; AVR, aortic valve replacement; BNP, B-type natriuretic peptide; BP, blood pressure; CCT, cardiovascular computed tomography; COR, class of recommendation; EACTS, European Association for Cardio-Thoracic Surgery; ESC, European Society of Cardiology; HF, heart failure; LV, left ventricle; LVEF, left ventricular ejection fraction; QoL, quality of life; SAVR, surgical aortic valve replacement; STS-PROM, Society of Thoracic Surgeons predicted risk of mortality; SVi, stroke volume index; TAVI, transcatheter aortic valve implantation; VHD, valvular heart disease; Vmax, peak transvalvular velocity.