The most appropriate management is to proceed to surgery with anesthesiology consultation. This patient has asymptomatic severe aortic stenosis, a condition that previously had been associated with a high risk of adverse cardiac events. However, advances in anesthetic and surgical techniques have led to a significant decrease in perioperative complications, and newer data indicate only a twofold increase in risk of postoperative myocardial infarction and 30-day mortality. The American College of Cardiology/American Heart Association (ACC/AHA) and American College of Chest Physicians (ACCP) guidelines recommend that elective noncardiac surgery is reasonable to perform in patients with asymptomatic severe aortic stenosis with appropriate intraoperative and postoperative hemodynamic monitoring (as can be determined by anesthesiology consultation). The risks of surgical delay must be weighed against the risks of the procedure. In this patient who meets no criteria for aortic valve replacement and is losing the ability to perform activities of daily living, performance of elective shoulder arthroscopy offers the best balance of risks.

Delaying or foregoing surgery would avoid potential perioperative risks but would also leave the patient with significant disability that could endanger her ability to remain independent in the community.

Dobutamine stress echocardiography is not indicated because the patient underwent an appropriate stress test less than 1 year ago and had no evidence of ischemia or symptoms after achievement of target heart rate and 4 metabolic equivalents (METs).

Repeat echocardiography would provide little additional value because this patient's cardiac structure and function are highly unlikely to have changed in less than 1 year. The ACC/AHA guideline recommends preoperative echocardiography for patients with moderate or worse valvular disease if it has been more than 1 year since the last study or the patient has had a change in clinical status.