Predictors of rapid disease progression include older age, more severe valve calcification, and a faster rate of hemodynamic progression on serial studies. In patients with an aortic velocity >4 m/s in addition to predictors of rapid disease progres- sion, symptom onset is likely in the near future, so there is less benefit to waiting for symptom onset. Thus, elective AVR may be considered if the sur- gical risk is low and after consideration of other clinical factors and patient preferences. In adults with initially asymptomatic severe AS, the rate of sudden death is low (<1% per year). However, an aortic velocity 5 m/s or an LVEF <60% each is associated with higher all-cause and cardiovascular mortality rates in the absence A multivariate analysis of predictors of death in a large cohort (>500 patients) showed a >4-fold higher risk of cardiovascular death for those with an LVEF <60% than for those with a A progressive decrease in LVEF is most likely in those with an LVEF <60% before AS becomes Evaluation for other causes of a decline in LVEF is appropriate, particularly when AS is not yet severe, but a progressive decline in LV systolic function is of concern and should prompt more frequent evaluation; and consider- ation of AVR when repeat studies show a progres- sive decline in LVEF without other cause with a lack of response to medical therapy. The presence of at least 3 serial imaging studies showing a con- sistent decline in LVEF ensures that the changes seen are not simply attributable to recording, measurement, or physiological variability.8 11 Hemodynamic progression eventually leading to symptom onset occurs in nearly all asymptom- atic patients with AS. 