Aortic stenosis

Last reviewed: 4 Sep 2023

Last updated: 16 Aug 2022

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.

Definition

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
fatigue
chest pain
exertional syncope
ejection systolic murmur
S2 diminished and single
carotid parvus et tardus

More key diagnostic factors

Other diagnostic factors

paradoxically split S2
Gallavardin phenomenon
bleeding

Other diagnostic factors

Risk factors

age >60 years
congenitally bicuspid aortic valve
rheumatic heart disease
chronic kidney disease
radiation therapy
high low-density lipoprotein (LDL)-cholesterol
hyperlipoproteinemia
hypertension
elevated lipoprotein(a)

More risk factors

Diagnostic investigations

1st investigations to order

transthoracic echocardiogram (including Doppler)
ECG
chest x-ray

More 1st investigations to order

Investigations to consider

cardiac MRI
cardiac catheterization
ECG exercise stress testing
dobutamine stress echo

More investigations to consider

Treatment algorithm

INITIAL

clinically unstable

ACUTE

clinically stable: symptomatic

clinically stable: asymptomatic

Contributors

Authors

Matthew Czarny, MD

Assistant Professor of Medicine

Department of Cardiovascular Medicine

Johns Hopkins University School of Medicine

Baltimore

Disclosures

MZ is a non-funded site co-investigator for the Medtronic trial of transcatheter aortic valve replacement (TAVR) in low surgical risk patients.

Rani Hasan, MD

Assistant Professor of Medicine

Department of Cardiovascular Medicine

Johns Hopkins University School of Medicine

Baltimore

Disclosures

RH declares that he has no competing interests.

Acknowledgements

Dr Matthew Czarny and Dr Rani Hassan would like to gratefully acknowledge Dr Girish L. Kalra and Dr Vasilis Babaliaros, previous contributors to this topic.

Disclosures

GLK declares that he has no competing interests. VB is a co-investigator in the PARTNER trial, and he has served as a consultant for Edwards Lifesciences and Abbott Vascular.

Peer reviewers

Peter Block, MD

Professor of Medicine

Emory University School of Medicine

Atlanta

Disclosures

PB declares that he has no competing interests.

Ghada Mikhail, BSc, MD, FRCP

Consultant Cardiologist and Honorary Senior Lecturer

Imperial College Healthcare NHS Trust

Hammersmith Hospital

London

Disclosures

GM has been supported by Edwards Lifesciences (manufacturer of the Edwards Sapien Transcatheter Valve) for attending cardiology conferences. Both Edwards Lifesciences and Medtronic (manufacturer of the CoreValve Transcatheter Valve) are contributing to an educational course on the transcatheter and surgical treatments of aortic and mitral valve disease. Edwards Lifesciences are supporting a research project on transcatheter treatment of aortic valve disease.

Juan M. Sztajzel, MD

Consultant

Cardiology Center

University Hospital Geneva

Geneva

Switzerland

Disclosures

JMS declares that he has no competing interests.

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Guidelines
- Guidelines on the management of valvular heart disease
- 2020 AHA/ACC guideline for the management of patients with valvular heart disease
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Patient leaflets
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Videos
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Aortic stenosis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

clinically unstable

clinically stable: symptomatic

clinically stable: asymptomatic

Contributors

Authors

Matthew Czarny, MD

Disclosures

Rani Hasan, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Peter Block, MD

Disclosures

Ghada Mikhail, BSc, MD, FRCP

Disclosures

Juan M. Sztajzel, MD

Disclosures

Differentials

Guidelines

Patient leaflets

Videos

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice