Aortic stenosis 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.
Aortic stenosis (AS) represents obstruction of blood flow across the aortic valve due to pathologic narrowing. It is a progressive disease that presents after a decades-long subclinical period with symptoms of fatigue, decreased exercise capacity, exertional dyspnea, exertional chest pain (angina), syncope, and heart failure.
History and exam
Key diagnostic factors
- exertional dyspnea
- chest pain
- exertional syncope
- ejection systolic murmur
- S2 diminished and single
- carotid parvus et tardus
Other diagnostic factors
- paradoxically split S2
- Gallavardin phenomenon
- age >60 years
- congenitally bicuspid aortic valve
- rheumatic heart disease
- chronic kidney disease
- radiation therapy
- 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 catheterization
- ECG exercise stress testing
- dobutamine stress echo
clinically stable: symptomatic
clinically stable: asymptomatic
- Aortic sclerosis
- Ischemic heart disease
- Hypertrophic cardiomyopathy (HCM)
- Guidelines on the management of valvular heart disease
- 2020 AHA/ACC guideline for the management of patients with valvular heart disease
Aortic stenosisMore Patient leaflets
How to perform an ECG: animated demonstrationMore videos
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