I rely on exercise echo.

I rely on cardiopulmonary exercise testing and BNP

I only rely on the ECHO parameters. If it is severe aortic stenosis (area less than 1cm2, transvalvular gradient above 40mmHg, transvalvular jet above 3m/sec), it means the patient is a candidate for surgery in my practice. Nothing else is needed. 

All dates cost efecctive possible because surgery is not unique option. These patients not uncommonly goes to TAVR and refine like specle tracking in echo and others are necessary sometimes; Clearly, the maximal caution in judge what to  do to rely is mandatory 

I only rely on echo parameters if all findings are coherent with the clinic assessment. In patients with LV dysfuncion and low LVEF transaortic gradient assessment can be very difficult and in selected patients echo stress can be of help. Remember that  severe aortic stenosis is an absolute contraindication to stress test.

Symptomatic severe aortic stenosis is an absolute contraindication to stress test, but the asyntomatic form is only a relative controindication. In my experience, I had no complications in over 100 patients.

Sometimes, some patients with severe heart disease have no symptoms, apparently. Actually, they reduced unawares the normal activity and so are symptomatics to all effects. I think that severe aortic stenosis (mean transaortic pressure gradient of 40 mmHg or more and aortic valve area of 1.0 cmq or less) is a life threatening condition and should to be treated as soon as possible. There are also two parameter which should to be considered: the patient's age and the severity of left ventricular hypertrophy. A frequent concomitant coronary artery disease should to be also excluded. No tests but surgery for these risky patients, obviously after to have obtained their informed consent.

Usefulness of atrial function for risk stratification in asymptomatic severe aortic stenosis

Journal of Cardiology05/2015; DOI: 10.1016/j.jjcc.2015.04.010.

Hope this article answer your question.

I only rely on echo parameters according to clinical dates. I think that the echo has great importance in the diagnosis and prognosis, but I think the refinement of technique should be guided by clinical data.

I rely on supine bicycle stress echo.

 The ECHO parameters is the only that we need.

In my practice  , if severe symptomatic aortic stenosis  is present , it means that the patient is a candidate for surgery .  Quantitative Doppler exercise echocardiography could be useful to identify a high-risk subset of patients with asymptomatic valvular aortic stenosis and help for clinical decision making.

When the clinical history is unclear, standard treadmill exercise testing is helpful to detect provoked symptoms, ensure that blood pressure rises appropriately, and measure exercise capacity objectively. There is an old saying in cardiology, to wit, "It's hard to make an asymptomatic patient feel better."

Traditionally exercise testing in patients with moderate to severe AS was contraindicated. We now have good evidence that 1) it can be safely performed by experienced individuals and 2) many "asymptomatic" patients become "symptomatic" when physiological stressed. When not being stressed they are asymptomatic as they have limited their lifestyle, consciously or unconsciously, to avoid provoking symptoms. The recent introduction of trans-catheter aortic valve repair/replacement is contributing to issues such as this one as thus far it has allowed "non-surgical valve replacement in patients considered to be at too high of risk for conventional OHS and valve replacement.

I would end with the following caveats; be familiar with the skills of the echocardiographer, the exercise stress team and your cardiac surgeons. Outcomes in valve surgery correlate quite well with the experience of the cardiac surgeon.

I would refer you to the following references, in especially the recent review by Otto and Prendergast: Aortic-Valve Stenosis — From Patients at Risk to Severe Valve Obstruction. Catherine M. Otto, M.D., and Bernard Prendergast, D.M. N Engl J Med 2014; 371:744-756August 21, 2014DOI: 10.1056/NEJMra1313875

Rajani R, Rimington H, Chambers JB. Treadmill exercise in apparently asymptomatic patients with moderate or severe aortic stenosis: relationship between cardiac index and revealed symptoms. Heart 2010;96:689-695

Marechaux S, Hachicha Z, Bellouin A, et al. Usefulness of exercise-stress echocardiography for risk stratification of true asymptomatic patients with aortic valve stenosis. Eur Heart J 2010;31:1390-1397

Makkar RR, Fontana GP, Jilaihawi H, et al. Transcatheter aortic-valve replacement for inoperable severe aortic stenosis. N Engl J Med 2012;366:1696-1704[Erratum, N Engl J Med 2012;367:881.

Kodali SK, Williams MR, Smith CR, et al. Two-year outcomes after transcatheter or surgical aortic-valve replacement. N Engl J Med 2012;366:1686-1695

The question is slightly confusing for in our practice Aortic Stenosis may also mean Stenosis of Aorta due to Aortoarteritis, an entirely different problem.

I believe we are only discussing disease of the aortic valve itself, not of the vessel.

Exercise testing is not enitrely an objective measure. For example what is an appropriate exercise capacity in an 80 year old. What stage/time does a patient need to complete before you can call them asymptomatic?  Although I agree exercise testing is useful and can determine patients develop symptoms on exertion it is not always clear-cut.

For functional capacity evaluation only a cardipulmonary execise testing is appropriate.

Is there any data on cardio-pulmonary exercise testing?

The value of cardiopulmonary exercise testing in individuals with apparently asymptomatic severe aortic stenosis: a pilot study.Levy F, Fayad N, Jeu A, Choquet D, Szymanski C, Malaquin D, Peltier M, Tribouilloy C.

Ventilatory efficiency predicts adverse cardiovascular events in asymptomatic patients with severeaortic stenosis and preserved ejection fraction.Dominguez-Rodriguez A, Abreu-Gonzalez P, Mendez-Vargas C, Martin-Cabeza M, Gonzalez J, Garcia-Baute Mdel C, de la Rosa A, Laynez-Cerdeña I.Int J Cardiol. 2014 Dec 20;177(3):1116-8

Asymptomatic severe aortic stenosis: role of cardiopulmonary exercise testing].Dominguez-Rodriguez A, Abreu-Gonzalez P. Med Clin (Barc). 2015 Apr 20;144(8):379-80

Cardiopulmonary responses to exercise and its utility in patients with aortic stenosis.Dhoble A, Enriquez-Sarano M, Kopecky SL, Abdelmoneim SS, Cruz P, Thomas RJ, Allison TG. Am J Cardiol. 2014 May 15;113(10):1711-6.