We read with interest the latest published European Society of Cardiology and American Heart Association guidelines on the management of valvular heart disease.

Our attention was focused on the section dealing with the natural history of aortic stenosis (AS), particularly on these lines: “In most patients with severe AS, impaired platelet function and decreased levels of von Willebrand factor can be demonstrated. The severity of the coagulation abnormality correlates with the severity of AS and resolves after valve replacement . … After the onset of symptoms, average survival is 2 to 3 years, 10% to 11% with a high risk of sudden death. Thus, the development of symptoms identifies a critical point in the natural history of AS. The management decisions are based largely on these data; most clinicians treat asymptomatic patients conservatively, whereas corrective surgery is generally recommended in patients with symptoms thought to be due to AS. Symptoms may be subtle and often are not elicited by the physician in taking a routine clinical history.”

In patients with “asymptomatic” severe AS, anemia significantly affects long-term outcomes. In addition, valve replacement appears to offer the best hope of long-term resolution of the bleeding and should be considered in most cases. So is it correct to consider as asymptomatic patients with severe AS and severe anemia directly linked to impaired platelet function and decreased levels of von Willebrand factor due to the valvulopathy? In our view, the guidelines should explain clearly the management, medical or surgical, of patients who bleed because of impaired platelet function and decreased levels of von Willebrand factor.