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For further information, see CMDT Part 10-14: Aortic Stenosis

Key Features

Essentials of Diagnosis

  • Congenital bicuspid aortic valve, usually asymptomatic until middle or old age

  • "Degenerative" or calcific aortic stenosis; similar risk factors as atherosclerosis

  • Visual observation of immobile aortic valve plus a valve area of < 1.0 cm2 define severe disease

  • Delayed and diminished carotid pulses

  • Soft, absent, or paradoxically split S2

  • Harsh systolic murmur, sometimes with thrill along left sternal border, often radiating to the neck; may be louder at apex in older patients

  • Echocardiography/Doppler is diagnostic

General Considerations

  • There are two common clinical scenarios in which aortic stenosis is prevalent

    • Congenitally abnormal unicuspid or bicuspid valve, rather than tricuspid

      • Symptoms can occur in young or adolescent individuals if the stenosis is severe but more often emerge at age 50–65 years

      • A dilated ascending aorta may accompany the bicuspid valve

      • Coarctation of the aorta is seen in patients with congenital aortic stenosis

      • Offspring of patients with a bicuspid valve have a much higher incidence of the disease in either the valve, the aorta, or both

    • Degenerative or calcific aortic stenosis

      • May be related to calcium deposition as occurs in atherosclerotic vascular disease

      • Approximately 25% of patients over age 65 years and 35% of those over age 70 years have echocardiographic evidence of aortic valve thickening

      • Hemodynamically significant aortic stenosis will develop in about 10–20% of these patients over 10–15 years

      • A genetic component appears a likely contributor

  • Risk factors include

    • Hypertension

    • Hypercholesterolemia

    • Smoking

  • Aortic stenosis has become the most common surgical valve lesion in developed countries

  • Many patients are elderly

  • Hypertrophic obstructive cardiomyopathy may coexist with valvular aortic stenosis

Clinical Findings

Symptoms and Signs

Mild to moderate aortic stenosis

  • Slightly narrowed, thickened, or roughened valves (aortic sclerosis) or aortic dilation may contribute to the typical ejection murmur of aortic stenosis

  • When the valve is still pliable, an ejection click may precede the murmur and the closure of the valve (S2) is preserved

  • The characteristic systolic ejection murmur is heard at the aortic area and is usually transmitted to the neck and apex

  • In some cases, only the high-pitched components of the murmur are heard at the apex, and the murmur may sound like mitral regurgitation (so-called Gallaverdin phenomenon)

Severe aortic stenosis

  • LV failure, angina pectoris, or syncope

    • May be presenting symptoms

    • Tend to first occur with exertion

  • A palpable LV heave or thrill, a weak to absent aortic second sound, or reversed splitting of the second sound

  • Prolonged ventricular systole and typical carotid pulse pattern of delayed upstroke and low amplitude

    • Present when the valve area is < 0.8–1.0 cm2 (normal, 3–4 cm2)

    • May be an unreliable finding in older ...

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