Prognostic significance implications of aortic valve sclerosis in the development of aortic stenosis: a systematic review and meta-analysis

BACKGROUND: Fibrocalcific aortic valve sclerosis (AVSc), the earliest manifestation of aortic stenosis (AS), is increasingly recognised as a marker of systemic vascular damage and adverse cardiovascular outcomes. While a subset of AVSc patients progresses to AS, reported rates vary widely. We conducted a systematic review and meta-analysis to better define the natural history of AVSc progression. METHODS: Following Preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, we searched PubMed, Scopus and Web of Science through July 2025 for observational studies reporting AS development in AVSc patients. Primary outcomes were progression to any degree of AS and to severe AS. Pooled event rates were calculated using a random-effects model. Heterogeneity and publication bias were assessed using standard statistical methods. Meta-regression explored associations with clinical and demographic variables. RESULTS: Eight studies (n=12 388 patients) reported on the progression of AVSc patients to any AS stage, and nine studies (n=19 486 patients) on the progression to severe AS. Over a median follow-up of 4.0 years, 14.1% of AVSc patients progressed to any AS stage (effect size: 0.14; 95% CI 0.02 to 0.53), and 2.0% to severe AS (effect size: 0.02; 95% CI 0.003 to 0.094). Heterogeneity was high, but no publication bias was detected. Meta-regression found no significant predictors of progression. CONCLUSIONS: Approximately one in six AVSc patients progresses to AS within 4 years, and 2% develop a severe disease. These findings underscore the importance of structured echocardiographic surveillance and support AVSc as a clinically relevant marker of systemic cardiovascular risk.