We read with interest the report by Freed et al related to reasons for nonadherence to guidelines for aortic valve replacement in severe aortic stenosis, and we want to congratulate the investigators for their contribution to this unresolved issue. They raise the difficult question of the indication for aortic valve replacement in supposedly asymptomatic patients or patients whose symptoms may be attributed to a different pathology, and they also discuss the role of exercise testing in determining the convenience of aortic valve replacement. In our opinion, this issue is still controversial in elderly patients, who constitute most patients with severe aortic stenosis.

First, there is an important discrepancy between the guidelines, because whereas the European Society of Cardiology has given a class I indication for exercise testing, the American College of Cardiology and American Heart Association have limited the indication to class II _B . Second, the studies on which these guidelines were based were developed with patients of much younger ages (44.2 ± 13 years in Amato et al’s series and 63 ± 16 years in Otto et al’s study), so the results can hardly be extrapolated to octogenarians. Last, the terms “symptomatic” and “truly asymptomatic” may be difficult to define in the elderly because there may exist huge variability in the quality of life and daily activities among individuals of the same age. Few doubts can exist in the assessment of the clinical status of a 72-year-old patient with severe aortic stenosis, especially using exercise testing. However, the scenario is completely different in a patient 10 years older. We are not sure that it is appropriate to assume that an octogenarian must be able to develop a given number of METs on an exercise test if perhaps half of those METs are enough in his or her daily activities. Moreover, with the progression of percutaneous valve implantation and its simplicity, it is expected that the threshold to indicate treatment of the aortic valve will be lower in the future. With the precedent of implantable defibrillators and particularly in the current context of severe economic restrictions in public health systems, we believe that it is mandatory to develop useful tools able to determine the clinical status of the increasing population of octogenarians with severe aortic stenosis, so that no treatment will be denied to patients who really need it while avoiding useless procedures that would overload public health systems.