Aortic stenosis (AS) is obstruction of blood flow across the aortic valve due to aortic valve fibrosis and calcification.
Presentation includes fatigue; exertional symptoms including shortness of breath, angina, or syncope; and heart failure.
Characteristic murmur is systolic, mid-to-late peaking with a crescendo-decrescendo pattern, and radiates to the carotids.
Doppler echo is essential to the diagnosis and will show a pressure gradient across the stenotic aortic valve.
Treatment of severe aortic stenosis with either a transcatheter or surgical valve prosthesis should be based primarily on symptoms or reduced ventricular systolic function. Earlier intervention may be considered if indicated by results of exercise testing, biomarkers, rapid progression, or the presence of very severe stenosis.
Choice of intervention should be a shared decision-making process, taking account of lifetime risks and benefits associated with the type of approach (transcatheter versus surgical) and type of valve (mechanical vs. bioprosthetic).
Following valve replacement, patients are subject to the complications of prosthetic valves.
AS represents obstruction of blood flow across the aortic valve due to pathological narrowing. It is a progressive disease that presents after a decades-long subclinical period.
History and exam
Key diagnostic factors
- presence of risk factors
- exertional dyspnoea
- chest pain
- exertional syncope
- ejection systolic murmur
- S2 diminished and single
- carotid parvus et tardus
Other diagnostic factors
- paradoxically split S2
- Gallavardin's phenomenon
- age >60 years
- congenitally bicuspid aortic valve
- rheumatic heart disease
- chronic kidney disease
- high low-density lipoprotein (LDL) cholesterol
- elevated lipoprotein(a)
1st investigations to order
- transthoracic echocardiogram (including Doppler)
- chest x-ray
Investigations to consider
- cardiac MRI
- cardiac CT
- cardiac catheterisation
- ECG exercise stress testing
- dobutamine stress echo
clinically stable: symptomatic
clinically stable: asymptomatic
- Aortic sclerosis
- Ischaemic heart disease
- Hypertrophic cardiomyopathy (HCM)
- Heart valve disease presenting in adults: investigation and management
- Guidelines on the management of valvular heart disease
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