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Background GLP-1 receptor agonists are recommended by NICE for weight management and cardiovascular risk reduction in eligible patients with obesity and type 2 diabetes. In aortic stenosis, obesity is associated with earlier symptom onset and increased functional limitation. Beyond metabolic benefits, GLP-1 receptor agonists demonstrate anti-inflammatory and anti-remodelling properties potentially relevant to aortic valve disease. We assessed adherence to NICE guidance for GLP-1 receptor agonist prescribing in patients with severe aortic stenosis undergoing valve replacement.Methods We retrospectively analysed 216 consecutive patients undergoing transcatheter or surgical aortic valve replacement at a single tertiary centre. NICE eligibility for GLP-1 receptor agonist therapy was determined based on BMI ≥35 kg/m 2 with type 2 diabetes, or BMI 30–34.9 kg/m2 with type 2 diabetes and specific comorbidities. Prescription status was extracted from medication records. Chi-square testing assessed the association between eligibility and prescription.Results Of 216 patients, 71 (32.9%) met NICE eligibility criteria for GLP-1 receptor agonist therapy. However, only 7 patients (3.2%) in the entire cohort received a prescription. Among eligible patients, just 2 (2.8%) were prescribed GLP-1 receptor agonists whilst 69 (97.2%) were not. There was no significant association between eligibility and prescription status (χ 2=0.56, p=0.76), indicating prescribing was not targeted to those meeting guideline criteria. Higher BMI patients experienced significantly greater symptom burden (p=0.003) and underwent intervention at younger ages (p=0.005), highlighting the clinical relevance of weight optimisation in this population.Conclusions There is marked underutilisation of GLP-1 receptor agonist therapy in patients with severe aortic stenosis who meet NICE eligibility criteria, with only 2.8% of eligible patients receiving treatment. Given that obesity accelerates symptomatic presentation and earlier intervention in aortic stenosis, this represents a missed opportunity for metabolic optimisation in a high-risk population. Improved adherence to NICE guidance may help delay symptom onset, optimise perioperative status, and potentially modify disease trajectory. Quality improvement initiatives are needed to address this prescribing gap.