AS (aortic stenosis)

Aortic stenosis is a common heart lesion that may occur in isolation or in combination with other heart defects. In the majority of cases, the aortic valve itself is narrowed by congenital deformity; for example, it may be bicuspid instead of tricuspid. Stenosis may then worsen with age as a result of thickening and calcification of the valve cusps.

The three classic symptoms of aortic stenosis are (1)

• angina,
• syncope, and
• heart failure

NICE guidance states (2):

Consider referring adults with asymptomatic severe aortic stenosis for intervention, if suitable, if they have any of the following:

• Vmax (peak aortic jet velocity) more than 5 m/s on echocardiography
• aortic valve area less than 0.6 cm2 on echocardiography
• left ventricular ejection fraction (LVEF) less than 55%
• B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) level more than twice the upper limit of normal
• symptoms unmasked on exercise testing.

Consider referring adults with symptomatic low-gradient aortic stenosis with LVEF less than 50% for intervention if during dobutamine stress echocardiography the aortic stenosis is shown to be severe by:

• a mean gradient across the aortic valve that increases to more than 40 mmHg and
• an aortic valve area that remains less than 1 cm2.

Consider measuring aortic valve calcium score on cardiac CT if the severity of symptomatic aortic stenosis is uncertain.

Offer enhanced follow up (for example, more frequent reviews) and further assessment (for example, stress echocardiography) to monitor the need for intervention if mid-wall fibrosis is detected on cardiac MRI in adults with severe aortic stenosis

A review suggests (3)

• when patients present with chest pain, breathlessness, presyncope, syncope, palpitations, or unexplained functional deterioration
  • auscultate for a systolic murmur (it can be soft)
• clinically relevant aortic stenosis is underdiagnosed
  • a clinician should consider transthoracic echocardiography and specialist assessment if there are cardiac or respiratory symptoms associated with an audible murmur
• arrange for urgent cardiology assessment (within 2 weeks) or acute admission for syncope and/or rapidly deteriorating symptoms in suspected aortic stenosis
• transcatheter procedures are suitable for many patients who might previously have been deemed unfit for open valve replacement surgery

Reference:

• Czarny MJ, Resar JR. Diagnosis and management of valvular aortic stenosis. Clin Med Insights Cardiol. 2014 Oct 19;8(Suppl 1):15-24.
• NICE (November 2021). Heart valve disease presenting in adults: investigation and management
• Hurrell H, Redwood M, Patterson T, Allen C. Aortic stenosis BMJ 2023; 380 :e070511 doi:10.1136/bmj-2022-070511