eMedicine Specialties > Emergency Medicine > Cardiovascular

Aortic Stenosis: Differential Diagnoses & Workup

Author: Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas Hospital
Coauthor(s): Daniel P Lombardi, DO, Clinical Assistant Professor, New York College of Osteopathic Medicine; Clinical Preceptor, Albert Einstein College of Medicine of Yeshiva University; Attending Physician and Interim Program Director, Department of Emergency Medicine, Saint Barnabas Hospital
Contributor Information and Disclosures

Updated: May 29, 2009

Differential Diagnoses

Acute Coronary Syndrome
Myocardial Infarction
Aortic Stenosis
Shock, Hypovolemic
Mitral Regurgitation
Mitral Stenosis
Mitral Valve Prolapse

Workup

Laboratory Studies

Laboratory studies are usually not helpful in making the diagnosis of aortic stenosis.

Imaging Studies

  • Chest radiography
    • Chest radiographs may show cardiac enlargement. Minimal enlargement and more subtle signs of concentric hypertrophy without dilatation are present, including mildly enlarged heart size, rounding at the cardiac apex, and slight backward displacement of the heart as seen in lateral view.
    • In later, more severe stages of aortic stenosis, radiographic signs of left atrial enlargement, pulmonary artery enlargement, right-sided enlargement, calcification of the aortic valve, and pulmonary congestion may be evident.
  • Echocardiography
    • Two-dimensional transthoracic echocardiography can confirm the clinical diagnosis of aortic stenosis and provide specific data on left ventricular function. It can show the structure and function of the other valves as well.


Aortic stenosis is seen on 2-dimensional echocard...

Aortic stenosis is seen on 2-dimensional echocardiography. Note thickened calcified leaflets.

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Aortic stenosis is seen on 2-dimensional echocard...

Aortic stenosis is seen on 2-dimensional echocardiography. Note thickened calcified leaflets.

    • The following 3 significant findings can help define the severity of the disease and describe the current hemodynamic significance:
      • An echo-dense aortic valve with no cusp motion is indicative of severe aortic stenosis. This may be unreliable in congenital or rheumatic valvular stenosis.
      • A decrease in the maximal aortic cusp separation (<8 mm in the adult) is also indicative of severe aortic stenosis.
      • The presence of otherwise unexplained left ventricular hypertrophy implies significant aortic stenosis.
    • Using echo-Doppler techniques, the systolic pressure gradient across the aortic valve can be assessed. Doppler techniques also can help visualize any mitral or aortic regurgitation that might be present.
    • Aortic stenosis can be classified based on the size of the aortic valve orifice (normal is 3–4 cm2 )2
      • Mild, if the area is >1.5 cm2
      • Moderate, if the area is 1–1.5 cm2
      • Severe, if the area is <1 cm2

Other Tests

  • Electrocardiography
    • Generally, ECG is not a reliable test because of the wide variations seen in aortic stenosis and other cardiac conditions.
    • An ECG of a patient with significant aortic stenosis most likely shows evidence of left ventricular hypertrophy with or without a strain pattern. T-wave inversion and ST-segment depressions are common.
    • While the degree of severity of changes on a single ECG does not correlate well with the degree of hemodynamic compromise, serial ECGs performed over time (months-years) can be valuable in demonstrating the progression of the disease.
    • Approximately 25% of patients with significant aortic stenosis may not show clear ECG evidence of ventricular hypertrophy. This population includes elderly persons who have significant myocardial fibrosis and adolescents who may experience ST-segment changes before QRS changes.
    • Of patients with significant aortic stenosis, 13% have conduction defects seen on ECG. These can include first-degree heart block, left bundle-branch block, and any other conduction defects.
    • The presence of left atrial enlargement suggests an associated mitral valve process.
  • Cardiac catheterization and coronary arteriography
    • Cardiac catheterization provides the most accurate measure of aortic stenosis.1
    • Perform cardiac catheterization and coronary arteriography on patients who may undergo surgery, are suspected of having coronary artery disease, or are older than 40 years (even without significant symptoms).
    • These patients have a 50% incidence of underlying coronary artery disease. This is a significant consideration if the patient may undergo surgical intervention.
  • Other considerations in the complete workup of aortic stenosis include radionuclide studies to evaluate myocardial perfusion at rest and during exertion and exercise studies. Perform these tests cautiously on symptomatic patients.5

More on Aortic Stenosis

Overview: Aortic Stenosis
Differential Diagnoses & Workup: Aortic Stenosis
Treatment & Medication: Aortic Stenosis
Follow-up: Aortic Stenosis
Multimedia: Aortic Stenosis
References
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References

  1. Townsend CM, et al. Sabiston Textbook of Surgery. 18th ed. Saunders; 2008:1841-1844.

  2. Ashley EA, Niebauer J. Chap 9 - Valve disease. In: Cardiology Explained. London: Remedica; 2004.

  3. Valvular emergencies. In: Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York: McGraw-Hill; 2004:54.

  4. Aortic valve disease. In: Topol EJ, Califf RM, et al, eds. Textbook of Cardiovascular Medicine. Section Two. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2007:Chap 23.

  5. Pierard LA, Lancellotti P. Stress testing in valve disease. Heart. Jun 2007;93(6):766-72. [Medline].

  6. Braunwald E. Valvular heart disease. In: AS Fauci, ed. Harrison's Principles of Internal Medicine. New York: McGraw Hill; 1994:1059-1061.

  7. Crawley IS, Morris DC, Silverman BD. Valvular heart disease. In: JW Hurst, ed. The Heart. 4th ed. New York: McGraw-Hill; 1978:922-1080.

  8. Edwards JE. Pathology of acquired valvular disease of the heart. Semin Roentgenol. 1979;14(2):96-115. [Medline].

  9. Fyler DC. Aortic stenosis. In: AS Nadas, DC Fyler, eds. Nadas Pediatric Cardiology. Philadelphia: Hanley and Belfus; 1992:493-511.

  10. Lam YY, Kaya MG, Li W, Gatzoulis MA, Henein MY. Effect of chronic afterload increase on left ventricular myocardial function in patients with congenital left-sided obstructive lesions. Am J Cardiol. Jun 1 2007;99(11):1582-7. [Medline].

  11. Lindroos M, Kupari M, Heikkila J, Tilvis R. Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample. J Am Coll Cardiol. 1993;21(5):1220-5. [Medline].

  12. Otto CM. Statins for aortic stenosis? Still waiting for answers. Nat Clin Pract Cardiovasc Med. Jul 2007;4(7):358-9. [Medline].

  13. Rahimtoola SH, Chandraratna PAN. Valvular heart disease. In: Clinical Medicine. Vol 6. 1983:1-51.

  14. Tzemos N, Therrien J, Yip J, Thanassoulis G, Tremblay S, Jamorski MT, et al. Outcomes in adults with bicuspid aortic valves. JAMA. Sep 17 2008;300(11):1317-25. [Medline].

  15. Welsh RC, Tymchak WJ. An unusual case of ST elevation in a 39-year-old man. Can J Cardiol. Feb 2000;16(2):215-7. [Medline].

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Further Reading

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Keywords

AS, aortic stenosis, congenital unicuspid or bicuspid valve, rheumatic fever, degenerative calcific changes of the valve, aortic valve, congestive heart failure, CHF, congenital cardiac defect, congenital heart defect, left ventricular failure, rheumatic disease, calcification of a congenital bicuspid valve, degenerative calcification of the valve

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Contributor Information and Disclosures

Author

Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas Hospital
Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Daniel P Lombardi, DO, Clinical Assistant Professor, New York College of Osteopathic Medicine; Clinical Preceptor, Albert Einstein College of Medicine of Yeshiva University; Attending Physician and Interim Program Director, Department of Emergency Medicine, Saint Barnabas Hospital
Daniel P Lombardi, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Medical Editor

Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Gary Setnik, MD, Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School
Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians and National Association of EMS Physicians
Disclosure: Intellicare Salary Management position; South Middlesex EMS Consortium Salary Management position

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Harvard Medical School; Associate-Chief, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Schering  Honoraria Speaking and teaching

 
 
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