Aortic stenosis (AS) is a number of different pathologies resulting in the narrowing of the aortic valve.
Prevalence increases with age.
Worldwide most commonly due to rheumatic heart disease but in Europe and the US most commonly due to degenerative scarring and calcification.
A degenerative pathologies lead to scarring, stiffening and narrowing of the aortic valve, either as a result of aging or a predisposing condition which leads to increased stress on the valve leaflets.
- Same mechanisms -->
Damage --> calcification
- Bicuspid (congenital)
- Increased turbulence → damage to leaflets → fibrosis/calcification and stenosis
Top three causes
- Degenerative Changes
- Congenital Biscuspid Aortic Valve
- Rheumatic valve disease (rarer)
Varies dependent on severity:
- Mild to moderate - often none
- Syncope or
- Especially on exertion
- Due to decreased brain
- Again on exertion
- Coronary arteries may be
- ↓BP → ↓coronary artery
- on exertion or decreased exercise
- Probably not due to
- May be just breathing hard
to increase O2 delivery to myocardium
- Symptoms of LVF
- Late - indicate very severe AS
4 Key signs
- Slow rising
- May not be
present in the elderly as loss of arteriolar elasticity masks effect
- Low B.P
- In elderly
this may be counteracted by the widened pulse pressure due to in-elastic
- Cannot distinguish severity
- Once very severe heart sound
becomes softer (Soft S2)
- Radiation to
- Hyperdynamic apex beat
- Left ventricular hypertrophy
- Soft S2
- Leaflets no longer slam shut
- Pulmonary oedema if severe
- Raised JVP if severe enough for Heart failure
Unless presenting as a new onset murmur with fever of unknown origin the always think Endocarditis (and appropriate tests)
- Anaemia may exacerbate symptoms
- In case of need to use diuretics
- Fasting Lipids
- To measure cardiac risk factors
- Chest X-ray
- May reveal signs of heart failure in advanced disease
- Can use doppler to judge ejection fraction
- Cardiac Catheterisation to measure pressure gradient across valve
- indicated if suspected but echocardiography is not diagnositic
- ECG (+/- exercise testing)
- to determine if the severity is sufficient to lead to Myocardial Ischaemia
- Measure and treat cardiovascular risk factors
- Monitoring of AS severity if asymptomatic
every three to five years.
every one to two years
every 6 to 12 months
Among patients with asymptomatic AS, there are no medical therapies that have been proven to delay progression of disease.
Aortic valve replacement
(Indicated once there is onset of symptoms)
Valve balloon plasty + insertion of valve graft.
Open surgery with valve replacement.