Aortic Stenosis Clinical Presentation
- Author: Xiushui (Mike) Ren, MD; Chief Editor: Richard A Lange, MD, MBA more...
Aortic stenosis usually has an asymptomatic latent period of 10-20 years. During this time, the LV outflow obstruction and the pressure load on the myocardium gradually increase. Symptoms develop gradually. Exertional dyspnea is the most common initial complaint, even in patients with normal LV systolic function, and it often relates to abnormal LV diastolic function. In addition, patients may develop exertional chest pain, effort dizziness or lightheadedness, easy fatigability, and progressive inability to exercise. Ultimately, patients experience the classic triad of chest pain, heart failure, and syncope.
Angina pectoris in patients with aortic stenosis is typically precipitated by exertion and relieved by rest. Thus, it may resemble angina from coronary artery disease.
Heart failure symptoms (ie, paroxysmal nocturnal dyspnea, orthopnea, dyspnea on exertion, and shortness of breath) may be due to systolic dysfunction from afterload mismatch, ischemia, or a separate cardiomyopathic process. Alternatively, diastolic dysfunction from LV hypertrophy or ischemia may also result in heart failure symptoms.
Syncope from aortic stenosis often occurs upon exertion when systemic vasodilatation in the presence of a fixed forward stroke volume causes the arterial systolic blood pressure to decline. It also may be caused by atrial or ventricular tachyarrhythmias.
Syncope at rest may be due to transient ventricular tachycardia, atrial fibrillation, or (if calcification of the valve extends into the conduction system) atrioventricular block. Another cause of syncope is abnormal vasodepressor reflexes due to increased LV intracavitary pressure (vasodepressor syncope).
Syncope may be accompanied by convulsions.
Patients with aortic stenosis may have a higher incidence of nitroglycerin-induced syncope than does the general population. Always consider aortic stenosis as a possible etiology for a patient who demonstrates particular hemodynamic sensitivity to nitrates.
Gastrointestinal bleeding due to angiodysplasia (ie, Heyde syndrome ) or other vascular malformations is present at a higher than expected frequency in patients with calcific aortic stenosis. These malformations usually resolve following aortic valve surgery.
Patients may present with manifestations of infective endocarditis (ie, fever, fatigue, anorexia, back pain, and weight loss). The risk of infective endocarditis is higher in younger patients with mild valvular deformity than in older patients with degenerated calcified aortic valves, but it can occur in either population. It can occur in patients of any age with hospital-acquired Staphylococcus aureus bacteremia.
Calcific aortic stenosis rarely may cause emboli of calcium to various organs, including the heart, kidney, and brain.
In severe aortic stenosis, the carotid arterial pulse typically has a delayed and plateaued peak, decreased amplitude, and gradual downslope (pulsus parvus et tardus). However, in elderly individuals with rigid carotid vessels, this sign may not be present. A lag time may be present between the apical impulse and the carotid impulse.
Systolic hypertension can coexist with aortic stenosis. However, a systolic blood pressure higher than 200 mm Hg is rare in patients with critical aortic stenosis.
Pulsus alternans can occur in the presence of LV systolic dysfunction. The jugular venous pulse may show prominent a waves reflecting reduced right ventricular compliance consequent to hypertrophy of the interventricular septum.
A hyperdynamic LV is unusual and suggests concomitant aortic regurgitation or mitral regurgitation.
S1 is usually normal or soft. The aortic component of the second heart sound, A2, is usually diminished or absent, because the aortic valve is calcified and immobile and/or the aortic ejection is prolonged and it is obscured by the prolonged systolic ejection murmur. The presence of a normal or accentuated A2 speaks against the presence of severe aortic stenosis.
Paradoxical splitting of the S2 also occurs, resulting from late closure of A2. P2 may also be accentuated in the presence of secondary pulmonary hypertension.
An ejection click is common in children and young adults with congenital aortic stenosis, but it is rare in elderly individuals with acquired calcific aortic stenosis, in whom the cusps become immobile and severely calcified. This sound occurs approximately 40-60 milliseconds after the onset of S1 and is frequently heard best along the mid to lower left sternal border; it is often well transmitted to the apex and may be confused with a split S1.
A prominent S4 can be present and is due to forceful atrial contraction into a hypertrophied left ventricle. The presence of an S4 in a young patient with aortic stenosis indicates significant aortic stenosis, but with aortic stenosis in an elderly person, this is not necessarily true.
The classic crescendo-decrescendo systolic murmur of aortic stenosis begins shortly after the first heart sound. The intensity increases toward midsystole, then decreases, and the murmur ends just before the second heart sound. It is generally a rough, low-pitched sound that is best heard at the second intercostal space in the right upper sternal border. It is harsh at the base and radiates to 1 or both carotid arteries.
In elderly persons with calcific aortic stenosis, however, the murmur may be more prominent at the apex, because of radiation of its high-frequency components (Gallavardin phenomenon). This may lead to its misinterpretation as a murmur of mitral regurgitation. Accentuation of the aortic stenosis murmur following a long R-R interval (as in atrial fibrillation or following a premature beat) distinguishes it from the mitral regurgitation murmur, which usually does not change.
The intensity of the systolic murmur does not correspond to the severity of aortic stenosis; rather, the timing of the peak and the duration of the murmur corresponds to the severity of aortic stenosis. The more severe the stenosis, the longer the duration of the murmur and the more likely it peaks at late systole.
The murmur of valvular aortic stenosis is augmented upon squatting or following a premature beat; the murmur intensity is reduced during Valsalva strain. This is contrary to what occurs with hypertrophic obstructive cardiomyopathy, in which a Valsalva maneuver increases the intensity of the murmur.
When the left ventricle fails and cardiac output falls, the aortic stenosis murmur becomes softer and may be barely audible. Atrial fibrillation with short R-R intervals can also decrease the murmur intensity or make it inaudible.
A high-pitched, diastolic blowing murmur may be present if the patient has associated aortic regurgitation.
Rarely, right ventricular failure with systemic venous congestion, hepatomegaly, and edema precede LV failure. This is probably due to the bulging of the interventricular septum into the right ventricle, with impedance in filling, elevated jugular venous pressure, and a prominent a wave (Bernheim effect).
Smith JG, Luk K, Schulz CA, et al. Association of low-density lipoprotein cholesterol-related genetic variants with aortic valve calcium and incident aortic stenosis. JAMA. 2014 Nov 5. 312(17):1764-71. [Medline].
Tintinalli JE, Kelen GD, Stapczynski JS, eds. Valvular emergencies. 6th ed. Emergency Medicine: A Comprehensive Study Guide. New York: McGraw-Hill; 2004. 54.
Bergler-Klein J. Natriuretic peptides in the management of aortic stenosis. Curr Cardiol Rep. 2009 Mar. 11(2):85-93. [Medline].
Townsend CM, et al. Sabiston Textbook of Surgery. 18th ed. Saunders; 2008:1841-1844.
Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, Baumgartner H, et al. Guidelines on the management of valvular heart disease (version 2012): The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2012 Oct. 33(19):2451-96. [Medline].
[Guideline] Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2006 Aug 1. 48(3):e1-148. [Medline].
Tzemos N, Therrien J, Yip J, Thanassoulis G, Tremblay S, Jamorski MT, et al. Outcomes in adults with bicuspid aortic valves. JAMA. 2008 Sep 17. 300(11):1317-25. [Medline].
Hughes BR, Chahoud G, Mehta JL. Aortic stenosis: is it simply a degenerative process or an active atherosclerotic process?. Clin Cardiol. 2005 Mar. 28(3):111-4. [Medline].
Roberts WC, Vowels TJ, Ko JM. Comparison of interpretations of valve structure between cardiac surgeon and cardiac pathologist among adults having isolated aortic valve replacement for aortic valve stenosis (+/- aortic regurgitation). Am J Cardiol. 2009 Apr 15. 103(8):1139-45. [Medline].
Kerstjens-Frederikse WS, Du Marchie Sarvaas GJ, et al. Left ventricular outflow tract obstruction: should cardiac screening be offered to first-degree relatives?. Heart. 2011 Aug. 97(15):1228-32. [Medline].
Lancellotti P, Magne J, Donal E, et al. Clinical outcome in asymptomatic severe aortic stenosis insights from the new proposed aortic stenosis grading classification. J Am Coll Cardiol. 2012 Jan 17. 59(3):235-43. [Medline].
Jander N, Minners J, Holme I, et al. Outcome of patients with low-gradient "severe" aortic stenosis and preserved ejection fraction. Circulation. 2011 Mar 1. 123(8):887-95. [Medline].
Rodrigues Tda R, Sternick EB, Moreira Mda C. Epilepsy or syncope? An analysis of 55 consecutive patients with loss of consciousness, convulsions, falls, and no EEG abnormalities. Pacing Clin Electrophysiol. 2010 Jul. 33(7):804-13. [Medline].
Topol EJ, Califf RM, et al, eds. Aortic valve disease. Textbook of Cardiovascular Medicine. Section Two. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2007:. Chap 23.
Zegdi R, Ciobotaru V, Huerre C, Allam B, Bouabdallaoui N, Berrebi A, et al. Detecting aortic valve bicuspidy in patients with severe aortic valve stenosis: high diagnostic accuracy of colour Doppler transoesophageal echocardiography. Interact Cardiovasc Thorac Surg. 2013 Jan. 16(1):16-20. [Medline]. [Full Text].
Zamorano JL, Badano LP, Bruce C, et al. EAE/ASE recommendations for the use of echocardiography in new transcatheter interventions for valvular heart disease. Eur Heart J. 2011 Sep. 32(17):2189-214. [Medline].
Messika-Zeitoun D, Aubry MC, Detaint D, Bielak LF, Peyser PA, Sheedy PF, et al. Evaluation and clinical implications of aortic valve calcification measured by electron-beam computed tomography. Circulation. 2004 Jul 20. 110(3):356-62. [Medline].
Shah RG, Novaro GM, Blandon RJ, Whiteman MS, Asher CR, Kirsch J. Aortic valve area: meta-analysis of diagnostic performance of multi-detector computed tomography for aortic valve area measurements as compared to transthoracic echocardiography. Int J Cardiovasc Imaging. 2009 Aug. 25(6):601-9. [Medline].
Bergler-Klein J, Klaar U, Heger M, Rosenhek R, Mundigler G, Gabriel H, et al. Natriuretic peptides predict symptom-free survival and postoperative outcome in severe aortic stenosis. Circulation. 2004 May 18. 109(19):2302-8. [Medline].
Brown DW, Dipilato AE, Chong EC, Gauvreau K, McElhinney DB, Colan SD, et al. Sudden unexpected death after balloon valvuloplasty for congenital aortic stenosis. J Am Coll Cardiol. 2010 Nov 30. 56(23):1939-46. [Medline].
Agarwal A, Kini AS, Attanti S, Lee PC, Ashtiani R, Steinheimer AM, et al. Results of repeat balloon valvuloplasty for treatment of aortic stenosis in patients aged 59 to 104 years. Am J Cardiol. 2005 Jan 1. 95(1):43-7. [Medline].
Wood S. New valve guidelines offer staging, risk-scoring advice. Medscape Medical News. March 5, 2014. [Full Text].
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Mar 3. [Medline].
Rahimtoola SH. Choice of prosthetic heart valve in adults an update. J Am Coll Cardiol. 2010 Jun 1. 55(22):2413-26. [Medline].
Stassano P, Di Tommaso L, Monaco M, Iorio F, Pepino P, Spampinato N, et al. Aortic valve replacement: a prospective randomized evaluation of mechanical versus biological valves in patients ages 55 to 70 years. J Am Coll Cardiol. 2009 Nov 10. 54(20):1862-8. [Medline].
Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010 Oct 21. 363(17):1597-607. [Medline].
Clavel, MA, et al. Comparison Between Transcatheter and Surgical Prosthetic Valve Implantation in Patients With Severe Aortic Stenosis and Reduced Left Ventricular Ejection Fraction. Circulation. Nov 9 2010Vol. . 122 No.19:
Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011 Jun 9. 364(23):2187-98. [Medline].
Daneault B, Kirtane AJ, Kodali SK, et al. Stroke associated with surgical and transcatheter treatment of aortic stenosis: a comprehensive review. J Am Coll Cardiol. 2011 Nov 15. 58(21):2143-50. [Medline].
Herrmann HC, Pibarot P, Hueter I, Gertz ZM, Stewart WJ, Kapadia S, et al. Predictors of Mortality and Outcomes of Therapy in Low-Flow Severe Aortic Stenosis: A Placement of Aortic Transcatheter Valves (PARTNER) Trial Analysis. Circulation. 2013 Jun 11. 127(23):2316-26. [Medline].
Hahn RT, Pibarot P, Stewart WJ, et al. Comparison of transcatheter and surgical aortic valve replacement in severe aortic stenosis: a longitudinal study of echocardiography parameters in cohort A of the PARTNER Trial (Placement of Aortic Transcatheter Valves). J Am Coll Cardiol. 2013 Jun 25. 61(25):2514-21. [Medline].
Adams DH, Popma JJ, Reardon MJ, Yakubov SJ, Coselli JS, Deeb GM, et al. Transcatheter Aortic-Valve Replacement with a Self-Expanding Prosthesis. N Engl J Med. 2014 Mar 29. [Medline].
Wood S. CoreValve Beats High-Risk Surgery for AV Stenosis in Pivotal Trial. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/822728. Accessed: April 8, 2014.
Neale T. FDA OKs expanded use for CoreValve. Medpage Today. June 12, 2014. [Full Text].
Medtronic, Inc. Medtronic CoreValve System receives FDA approval for patients at high risk for surgery [press release]. June 12, 2014. Available at http://newsroom.medtronic.com/phoenix.zhtml?c=251324&p=irol-newsArticle&ID=1939539&highlight=. Accessed: June 16, 2014.
[Guideline] Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003 May 21. 289(19):2560-72. [Medline].
[Guideline] Nishimura RA, Carabello BA, Faxon DP, et al. ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology. August 2008. 52:676-85. [Medline].
Moura LM, Ramos SF, Zamorano JL, Barros IM, Azevedo LF, Rocha-Gonçalves F, et al. Rosuvastatin affecting aortic valve endothelium to slow the progression of aortic stenosis. J Am Coll Cardiol. 2007 Feb 6. 49(5):554-61. [Medline].
Chan KL, Teo K, Dumesnil JG, Ni A, Tam J. Effect of Lipid lowering with rosuvastatin on progression of aortic stenosis: results of the aortic stenosis progression observation: measuring effects of rosuvastatin (ASTRONOMER) trial. Circulation. 2010 Jan 19. 121(2):306-14. [Medline].
Rossebo AB, Pedersen TR, Boman K, et al. Intensive lipid lowering with simvastatin and ezetimibe in aortic stenosis. N Engl J Med. 2008 Sep 25. 359(13):1343-56. [Medline].
Cowell SJ, Newby DE, Prescott RJ, et al. A randomized trial of intensive lipid-lowering therapy in calcific aortic stenosis. N Engl J Med. 2005 Jun 9. 352(23):2389-97. [Medline].
[Guideline] Wann LS, Curtis AB, Ellenbogen KA, et al. 2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Update on Dabigatran): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011 Mar 15. 123(10):1144-50. [Medline]. [Full Text].
Bagur R, Webb JG, Nietlispach F, Dumont E, De Larochellière R, Doyle D, et al. Acute kidney injury following transcatheter aortic valve implantation: predictive factors, prognostic value, and comparison with surgical aortic valve replacement. Eur Heart J. 2010 Apr. 31(7):865-74. [Medline]. [Full Text].
Eltchaninoff H, Prat A, Gilard M et al,. Transcatheter aortic valve implantation: early results of the FRANCE (FRench Aortic National CoreValve and Edwards) registry. Eur Heart Jl. 2011. 32:191–197.
FDA approval expands access to artificial heart valve for inoperable patients [press release]. Food and Drug Administration. September 23, 2013. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm369510.htm.
Lefevre T, Kappetein AP, Wolner E, et al. One year follow-up of the multi-centre European PARTNER transcatheter heart valve study. Eur Heart Jl. 2011. 32:148–157.
Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010 Oct 21. 363(17):1597-607. [Medline].
Prasad Y, Bhalodkar NC. Aortic sclerosis--a marker of coronary atherosclerosis. Clin Cardiol. 2004 Dec. 27(12):671-3. [Medline].
Rosenhek R, Zilberszac R, Schemper M, Czerny M, Mundigler G, Graf S, et al. Natural history of very severe aortic stenosis. Circulation. 2010 Jan 5. 121(1):151-6. [Medline].
Tamburino C, Capodanno D, Ramondo A, Petronio AS, Ettori F, Santoro G, et al. Incidence and predictors of early and late mortality after transcatheter aortic valve implantation in 663 patients with severe aortic stenosis. Circulation. 2011 Jan 25. 123(3):299-308. [Medline].
Wood S. Expanded FDA indication for Sapien valve. Medscape Medical News. September 24, 2013. [Full Text].
Zahn R, Gerckens U, EGrube E et al. Transcatheter aortic valve implantation: first results from a multi-centre real-world registry. Eur Heart Jl. 2011. 32:198–204.
Zajarias A, Cribier AG. Outcomes and safety of percutaneous aortic valve replacement. J Am Coll Cardiol. 2009 May 19. 53(20):1829-36. [Medline].
- Table 1. Common Causes of Aortic Stenosis Among Patients Requiring Surgery
- Table 2. ACC/AHA Recommendations for Echocardiography (Imaging, Spectral, and Color Doppler) in Aortic Stenosis
- Table 3. Criteria for Determining Severity of Aortic Stenosis
- Table 4. Recommendations for Cardiac Catheterization in Aortic Stenosis
- Table 5. Recommendations for Aortic Valve Replacement in Aortic Stenosis
|Age < 70 years (n=324)||Age >70 years (n=322)|
|Bicuspid AV (50%)
|Diagnosis and assessment of severity of aortic stenosis||I|
|Assessment of LV size, function, and/or hemodynamics||I|
|Reevaluation of patients with known aortic stenosis with changing symptoms or signs||I|
|Assessment of changes in hemodynamic severity and ventricular function in patients with known aortic stenosis during pregnancy||I|
|Reevaluation of asymptomatic patients with severe aortic stenosis||I|
|Reevaluation of asymptomatic patients with mild to moderate aortic stenosis and evidence of LV dysfunction or hypertrophy||IIa|
|Routine reevaluation of asymptomatic adult patients with mild aortic stenosis who have stable physical signs and normal LV size and function||III|
|Severity||Mean gradient (mm Hg)||Aortic valve area (cm2)|
(or < 0.5 cm2/m2 body surface area)
|Coronary angiography before aortic valve replacement in patients at risk for coronary artery disease||I|
|Assessment of severity of aortic stenosis in symptomatic patients when aortic valve replacement is planned or when noninvasive tests are inconclusive or a discrepancy exists in the clinical findings regarding the severity of aortic stenosis or the need for surgery||I|
|Coronary angiography before aortic valve replacement in patients for whom a pulmonary autograft (Ross procedure) is contemplated and the origin of the coronary arteries was not identified by noninvasive tests||I|
|With infusion of dobutamine, can be useful for evaluation of patients with low-flow/low-gradient aortic stenosis and LV dysfunction||IIa|
|Not recommended for hemodynamic measurements for assessment of aortic stenosis severity when noninvasive techniques are adequate and concord with clinical findings||III|
|Not recommended for hemodynamic measurements for assessment of LV function and aortic stenosis severity in asymptomatic patients||III|
|Symptomatic patients with severe aortic stenosis||I|
|Patients with severe aortic stenosis undergoing coronary artery bypass surgery||I|
|Patients with severe aortic stenosis undergoing surgery on the aorta or other heart valves||I|
|Patients with severe aortic stenosis and LV systolic dysfunction (ejection fraction < 0.50)||I|
|Patients with moderate aortic stenosis undergoing coronary artery bypass surgery or surgery on the aorta or other heart valves||IIa|
|Patients with mild aortic stenosis undergoing coronary artery bypass surgery when there is evidence that progression may be rapid, such as moderate-to-severe valve calcification||IIb|
|Asymptomatic patients with severe aortic stenosis and abnormal response to exercise (eg, hypotension)||IIb|
|Asymptomatic patients with severe aortic stenosis and a high likelihood of rapid progression (based on age, calcification, and coronary artery disease) or if surgery might be delayed at the time of symptom onset||IIb|
|Asymptomatic patients with extremely severe aortic stenosis (valve area less than 0.6 cm2, mean gradient greater than 60 mm Hg, and jet velocity greater than 5 m per second) if the patient’s expected operative mortality is 1% or less||IIb|
|AVR is not useful for prevention of sudden death in asymptomatic patients with none of the findings listed under asymptomatic patients with severe aortic stenosis||III|