Treadmill Stress Tests Safe, Reliable for Detecting Severe Asymptomatic Aortic Stenosis

Treadmill stress tests are a safe and effective method of identifying symptoms of severe aortic stenosis (AS) in patients previously deemed asymptomatic, according to recent research.¹

AS is among the most frequent valve diseases in older populations, and roughly 50% of these patients present with no symptoms at first diagnosis. For these patients, guidelines recommend exercise stress testing; however, data have shown that these tests are implemented in <10% of cases. Additionally, patients with severe AS and a positive stress test result have displayed poor prognoses if aortic valve replacement (AVR) is not prompt following diagnosis.¹

“If the patient is open to early intervention, I think early intervention should be the treatment of choice,” Philippe Généreux, MD, co-director of the Structural Heart Disease Program at Atlantic Health Morristown Medical Center and principal investigator in the study, told HCPLive in an exclusive interview. “Some patients will say, ‘This is not good timing, I don’t have symptoms, can I go travel for 2 weeks?’ I think to do a stress test, in this instance, is appropriate, even if just to reassure the patient.”

EARLY TAVR Study Structure

The original EARLY TAVR study was a prospective, multicenter, open-label, randomized controlled trial comparing TAVR with transfemoral placement of a balloon-expandable valve and clinical surveillance among asymptomatic patients. Patients were eligible for enrollment if they were ≥65 years of age and had asymptomatic severe AS with suitable anatomy for TAVR. Those with a left ventricular ejection fraction of <50% or any other class I indication for aortic-valve replacement were excluded, among other criteria. Asymptomatic status was determined via a low-level treadmill stress test.²

Eligible patients were randomly assigned in a 1:1 ratio to either clinical surveillance or early TAVR. Those assigned to the surveillance group received standard care according to American College of Cardiology and American Heart Association guidelines. Patients in this group who developed symptoms were able to convert to aortic-valve replacement via transfemoral TAVR or another strategy, as indicated. Patients in the early TAVR group underwent transfemoral TAVR. Both patient groups had planned clinical and echocardiographic assessments planned through 5 years.²

EARLY TAVR included a primary composite endpoint of death from any cause, stroke, or unplanned hospitalization for cardiovascular disease – any aortic valve intervention for the surveillance group within 6 months or aortic valve reintervention in the TAVR group within 6 months was considered unplanned hospitalization.²

A total of 901 patients were enrolled, of whom 455 were assigned to TAVR and 446 to surveillance. A primary endpoint event occurred in 122 patients in the TAVR group (26.8%) and 202 patients in the surveillance group (45.3%) (HR, 0.5; 95% CI, 0.4-0.63; P <.001). Death occurred in 8.4% of patients assigned to TAVR and 9.2% of patients in the surveillance group; stroke occurred in 4.2 and 6.7%, and unplanned hospitalization in 20.9% and 41.7%, respectively. During a median follow-up of 3.8 years, 87% of patients in the surveillance group underwent aortic valve replacement.²

The Treadmill Stress Test

The present study enrolled patients who had been excluded from EARLY TAVR due to a positive treadmill stress test. These patients were followed up with through 2 years via phone. Of the patients initially screened for the EARLY TAVR trial, 146 had a positive treadmill stress test result – of these, 105 consented to enroll in the EARLY TAVR Treadmill Registry.¹

Généreux and colleagues found during this registry that treadmill stress tests were safe, with no reported deaths, syncope, or cardioversions following the test. Multivariable baseline predictors of a positive treadmill stress test included higher peak velocity, lower ejection fraction, prior coronary artery bypass, and prior stroke. The 2-year Kaplan-Meier rate for all-cause mortality in this population was 5.7%. Patients with positive treadmill stress test results saw rates of AVR at 1 and 2 years of 79.9% and 85.9%, respectively. Mortality rates and AVR were similar for patients with a class I indication and those with a class IIa indication.¹

Ultimately, Généreux and colleagues concluded that the treadmill stress test was safe and effective in patients with asymptomatic severe AS. However, based on the follow-up data, roughly 20% of these patients remained untreated at 1 year despite having an indication for prompt treatment. Généreux encourages clinicians to not only make use of the treadmill stress test in their own practices, but to promptly refer or intervene in this patient population as well.¹

“In light of the findings of EARLY TAVR, you’re justified to refer promptly. I’m not saying to do the TAVR next week, but at least plan and get ready, so you have a procedure plan, you know what type of valve you’re going to use, what access, whether the patient is a surgical candidate or not,” Généreux said. “I think that everything points to prompt referral, prompt workup of the patient, and prompt intervention.”

Editor’s Note: Généreux reports disclosures with Abbott Vascular, Edwards Lifesciences, Medtronic, Puzzle Medical, Teleflex, Spiralis Medical, and others.

References

1. Généreux P, Schwartz A, Lindman BR, et al. Treadmill stress test in patients with asymptomatic severe aortic stenosis. JAMA Cardiology. July 22, 2026. Accessed August 18, 2026. doi:10.1001/jamacardio.2026.2527

2. Généreux P, Schwartz A, Oldemeyer JB, et al. Transcatheter aortic-valve replacement for asymptomatic severe aortic stenosis. NEJM. 2025;392(3):217-227. doi:10.1056/nejmoa2405880