Aortic Stenosis

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Aortic Stenosis
Charles W. Webb
Ryan C. Petering
  • Aortic stenosis is the most prevalent valvular heart disease. There are several terms that are used to describe different variants of aortic valve abnormalities.
    • Aortic sclerosis: Calcification or thickening of the aortic valve without outflow obstruction
    • Calcific aortic stenosis: Calcification on the aortic valve cusps that leads to outflow obstruction; most common etiology of aortic stenosis
    • Congenital bicuspid aortic valve: Aortic stenosis resulting from 2-leaflet aortic valve with symptoms developing in 1st or 2nd decade of life; frequently associated with coarctation of the aorta
    • Congenital aortic stenosis: Various valve structural abnormalities that lead to symptoms in childhood; less likely to be associated with heart failure and angina than adult onset aortic stenosis (1)
  • System(s) affected: Cardiovascular
  • Calcific aortic stenosis is frequency associated with age:
    • Ages 65–74: 1–3% prevalence
    • Ages 75–84: 2–4% prevalence
    • Age >85: >4% prevalence
  • Predominant gender: Male > Female (slightly)
  • Bicuspid aortic valve present in 1–2% of newborns
  • Bicuspid aortic valve occurs predominantly in males (1).
Risk Factors
  • The exact mechanism of aortic stenosis is unclear.
  • Proposed mechanisms include lipid accumulation, inflammation, and calcification.
  • Risk factors include:
    • Increasing age
    • Male gender
    • Hyperlipidemia
    • Active inflammation (2)
  • Classic triad of (1) dyspnea, (2) angina, and (3) syncope
  • Symptoms of heart failure (dyspnea on exertion, orthopnea, lower extremity edema)
  • Murmur: Harsh crescendo-decrescendo systolic murmur loudest over the right 2nd intercostal space with radiation toward the carotid artery
  • Parvus tardus: Slow, delayed carotid upstroke
  • Absent or diminished aortic component of 2nd heart sound (3)
Diagnostic Tests & Interpretation
There are no specific laboratory studies related to aortic stenosis.
  • CXR and electrocardiogram frequently will be abnormal, but changes are not specific nor sensitive in the diagnosis of aortic stenosis.
  • Transthoracic echocardiogram (TTE):
    • Mainstay for diagnosis and staging of aortic stenosis
    • Key measurements include left ventricular systolic function, hypertrophy, transvalvular pressure gradient, and aortic valve area.
    • Normal: Aortic jet velocity <2.5 m/s2, aortic valve area 3–4 cm2
    • Mild: Aortic jet velocity 2.5–2.9 m/s2, aortic valve area 1.5–2 cm2
    • Moderate: Aortic jet velocity 3–4 m/s2, aortic valve area 1–1.5 cm2
    • Severe: Aortic jet velocity >4 m/s2, aortic valve area <1 cm2 (3)
Diagnostic Procedures/Surgery
Cardiac catheterization is commonly performed as part of the diagnostic workup of aortic stenosis to rule out coexisting coronary artery disease (1).
Differential Diagnosis
  • Coronary artery disease
  • Congestive heart failure
  • Other valvular heart disease
Ongoing Care
  • Activity recommendations need to be individualized owing to often complicated picture of coexisting conditions in aortic stenosis patients.
  • Asymptomatic, mild aortic stenosis: No restrictions in activity
  • Asymptomatic, moderate–severe aortic stenosis: Avoid competitive and vigorous activity with high dynamic and static muscle demands. Otherwise, exercise is generally permitted.
  • Symptomatic aortic stenosis: Activity contraindicated (1)
Follow-Up Recommendations
Patient Monitoring
  • TTE monitoring by aortic stenosis severity:
    • Severe: Every 6–12 mos
    • Moderate: Every 1–2 yrs
    • Mild: Every 3–5 yrs
  • Treadmill stress testing can be used to help guide management of asymptomatic patients with moderate–severe aortic stenosis (3).
Patient Education
All asymptomatic patients who are being monitored need detailed education about the symptoms of heart failure.
  • 1% annual risk of sudden death with asymptomatic aortic stenosis
  • Average overall survival rate for symptomatic patients is 2–3 yrs without aortic valve replacement.
  • Aortic valve replacement surgery perioperative overall mortality is roughly 4%. There is great variability in risk based on patient age and coexisting conditions.
    • Patients without coexisting conditions and age 55–65 yrs: 1% risk
    • Patients with coexisting hypertension and coronary artery disease and age 85 yrs: 7% risk
    • Patients with coexisting hypertension, coronary artery disease, and previous cardiac catheterization and age 85 yrs: 24% risk (4)
1. Carabellow BA, Paulus WJ. Aortic stenosis. The Lancet. 2009;373:956–966.
2. Dal-Bianco JP, et al. Management of severe asymptomatic aortic stenosis. J Am Coll Cardiol. 2008;52:1279–1292.
3. Gimard BH, Larson JM. Aortic stenosis: diagnosis and treatment. Am Fam Physician. 2008;78(6):717–725.
4. Otto CM. Valvular aortic stenosis. J Am Coll Cardiol. 2006;47:2141–2151.
  • 424.1 Aortic valve disorders
  • 440.0 Atherosclerosis of aorta
  • 746.4 Congenital insufficiency of aortic valve

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