Medically Fit For Exams
Medically Fit For Exams

Aortic stenosis


  • Obstructed blood flow through the aortic valve, which could be calcific, congenital (biscuspid instead of tricuspid) or pathological changes as a result of rheumatic fever. Leads to obstructed left ventricular stroke volume


Risk factors

  • Rheumatic fever
  • Chronic kidney disease
  • Radiation exposure
  • Familial hypercholesterolaemia
  • Calcific aortic valvular disease risk factors:
    • Age
    • Male
    • Raised lipoprotein level
    • Raised LDL
    • Hypertension
    • Smoking
    • Diabetes


Differential diagnoses

  • Angina
  • Acute coronary syndrome
  • Heart failure
  • COPD
  • AF
  • Mitral regurgitation
  • Mitral stenosis



  • 5% over 75 have moderate or severe



  • Most cases caused by valvular obstruction
  • Most commonly by acquired calcification of leaflets (degenerative calcific aortic stenosis), which is associated with age and risk factors (above)
    • Result of haemodynamic stress on the valve
    • Leads to limited cusp opening during systole
  • May result from rheumatic fever, which leads to a progressive fibrosis of valve leaflets, which can lead to calcification and also retracted leaflets
    • Usually results in both stenosis and regurgitation
  • May be congenital in cause, with unicuspid, bicuspid or quadricuspid valves. Or have abnormal tricuspid valve
    • These lead to turbulent blood flow, and resulting calcium deposits and/or fibrosis


Clinical features

  • Classic triad of:
    • Exercise-induced chest pain
    • Exercise-induced syncope
    • SOB/heart failure symptoms
  • Small volume carotid pulse, slow rising, sinus rhythm
  • On auscultation:
    • Ejection systolic murmur, possible ejection click
    • Possible 4th heart sound (Tenessee)
    • Best heard over aortic area (right 2nd intercostal space)
    • Radiates to carotid
  • Palpation:
    • Possible systolic thrill (aortic area)
    • No apex displacement



  • Obstructed let ventricular emptying
  • Increased left ventricular pressure and compensatory left ventricular hypertrophy
  • Leads to relative ischaemia of local myocardium
  • Hence angina pain, ventricular failure and possible arrhythmias
  • Obstruction is more severe during exercise, as cardiac output would normally massively increase, but is prevented in aortic stenosis
  • Results in drop in BP, and syncope
  • Worsens myocardial ischaemia



  • CXR
    • May see aortic valve calcification
    • Aortic root ‘post stenotic’ dilatation
    • Heart not usually enlarged
  • ECG
    • Left ventricular hypertrophy
    • Left atrial delay
    • Ischaemia pattern
      • ST depression and T wave inversion in leads 1, AVL, V5 and V6
    • Usually sinus rhythm, may have arrhythmias
  • Echocardiogram
    • Thickened, calcified and immobile aortic cusps
    • Delayed peak velocity: normal = <1.7, mild = 1.7 – 2.9, mod = 3 – 4, severe = >4
    • Peak pressure drop (mmHg): <36 = mild, 36-64 = mod, >64 = severe
    • Mean pressure drop (mmHg): <25 = mild, 25-40 = mod, >40 = severe
    • Reduced valve area (cm2): normal = >2, mild = 1.5 – 2, mod = 1 – 1.4, severe = <1
  • Cardiac MRI to assess thoracic aorta for aneurysm, dissection or coarctation



  • All symptomatic patients should have aortic valve replacement if possible
  • Asymptomatic patients should have regular review
  • Surgery in asymptomatic patients is suggested if:
    • Symptomatic during exercise test or has drop in BP
    • Left ventricular ejection fraction <50%
    • Moderate-severe stenosis undergoing CABG, surgery of ascending aorta or other cardiac valve
  • Balloon dilatation can be used as alternative to surgery, but isn’t as effective, and usually just used a bridging measure, or when surgery is contraindicated
  • Percutaneous valve replacement has been trialled in those unsuitable for surgery: involved catheter insertion of a balloon expandable stent valve. Promising results so far
  • Congenital aortic valve abnormalities can be treated by valvotomy, with valve replacement following after a few years



  • After onset of symptoms (indicates moderate to severe disease), average 50% survival at 2 years, 20% survival at 5 years
  • Complications include increased risk of:
    • GI bleeding due to angiodysplasia (resolves after valve replacement)
    • Infective endocarditis
    • Dislodging of calculi to brain, kidneys, heart
    • Bicuspid valve increases risk of aortic root dilatation (25-40%) and aortic dissection

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