Aortic Stenosis

Cardiac outflow obstruction caused by narrowing of the aortic valve. Senile calcification is the most common cause.


Dyspnoea is the most common presenting feature
Presentation with syncope or angina usually indicates severe disease.
Classic triad of angina, syncope and heart failure normally after the age of 60


Duration and type of symptoms
Chest pain - angina history
Syncope - frequency, associated features, warning signs, postal hypotension, movement
Dyspnoea - Dyspnoea - onset, aggravating and relieving factors. Normal exercise tolerance.
Does the patient have any risk factors for developing vascular disease - Hypertension, hypercholesterolaemia, obesity, diabetes, previous acute coronary event/stroke, smoker, lifestyle/occupation, family history of ischaemic heart disease?
Childhood infections - rheumatic fever
PMHx - previous MI, COPD, pneumonia, valvular disease as a child
FH - history of congenital valve problems. Williams syndrome.

Vital signs / observations



Slow rising pulse with narrow pulse pressure. Diminished and delayed carotid upstroke - parvus et tardus

Ejection systolic murmur - heard at base, left sternal edge and aortic area, radiating to the carotids

S1 is usually normal. Quiet A2 is also common, and in severe aortic stenosis this may be inaudible. Ejection click may be heard or an S4
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Are there features of cardiac failure - pulmonary oedema, peripheral oedema

Bedside test

ECG - P-mitrale, LV hypertrophy or strain pattern, Left anterior hemiblock, poor R wave progression, LBBB or complete AV block

Laboratory investigations

FBC - anaemia may worsen symptoms

Radiological investigations

CXR - cardiomegaly and LVH. Calcified aortic valve
Echo - diagnostic and doppler may determine the gradient across the valves. Severe stenosis denied as gradient of >50mmHg and valve area <0.5cm2.
If aortic jet velocity is >4m/s then risk of complications increased

Cardiac catheterisation

This can assess the valve gradient, LV function and coronary artery disease
Risk of emboli with investigation



Follow up



If symptomatic then prognosis is poor without surgery: 2-3 year survival if angina/syncope; 1-2 year if cardiac failure
If moderate to severe treated medically mortality can be 50% at 2 years

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