Aortic Stenosis

Aka: Aortic Stenosis, Valvular Aortic Stenosis, Critical Aortic Stenosis, Heyde Syndrome

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II. Epidemiology

  1. Overall Prevalence in U.S. 3.7%
  2. Aortic Stenosis is the most significant cardiac valve disorder in the developed world
  3. Prevalence increases with age (U.S.)
    1. Age 50-60 years: 0.2%
    2. Age 60-70 years: 1.3%
    3. Age 70-80 years: 3.9%
    4. Age 80-90 years: 9.8%

III. Causes: Valvular

  1. Congenital Bicuspid Valve (Most common)
    1. Affects 1-2% of the U.S. population
    2. Twice as common in men
    3. Also associated with aortic root dilation
    4. Slow increase in stenosis (progressive sclerosis)
      1. Childhood: mild stenosis and asymptomatic
      2. Ages 20-40: moderate stenosis develops
      3. Over age 40: severe stenosis develops (occurs in >50%, requiring aortic Valve Replacement)
  2. Atherosclerosis (Calcific Aortic Valve Stenosis)
    1. Gradually develops, typically presenting over age 70 years
      1. Rarely severe (contrast with congenital )
    2. Similar pathway to atherosclerosis with valvular Plaque accumulation and inflammation
      1. Calcification occurs via Inflammatory response to LDL Cholesterol and Lipoprotein-A deposition
      2. Calcification affects normal aortic valves despite having 3 leaflets (tricuspid, in contrast to congenital bicuspid valve)
      3. Calcification of the aortic valve leads to aortic sclerosis with tissue rigidity
    3. Aortic sclerosis is a calcification of the aortic valve WITHOUT restriction of valve leaflet mobility
      1. Aortic sclerosis progresses to Aortic Stenosis in 2% of patients per year
      2. Aortic Stenosis gradually progresses to restrict the aortic valve opening
  3. Rheumatic Fever
    1. Slowly progressive stenosis
  4. Subacute Bacterial Endocarditis
  5. Other acquired aortic valve stenosis causes
    1. Systemic Lupus Erythematosus
    2. Fabry Disease
    3. Paget's Disease of Bone
    4. Rheumatoid Arthritis
    5. Radiation Exposure
  6. Other congenital aortic valve stenosis causes
    1. Aortic Coarctation
    2. Unicuspid aortic valve
      1. Very rare congenital defect presenting with Aortic Stenosis at a young age
      2. May be initially misdiagnosed as a bicuspid valve
    3. Williams Syndrome
    4. Shanes Complex
    5. Supravalvular Aortic Stenosis
      1. May be associated with Williams Syndrome or other congenital supravalvular Aortic Stenosis
    6. Subvalvular Aortic Stenosis
      1. May be associated with Hypertrophic Cardiomyopathy or other congenital subvalvular Aortic Stenosis
  7. References
    1. Baloor and Nayak (2018) Exam Preparatory Manual for Undergraduate Medicine, Jaypee Brothers Medical Publication

IV. Pathophysiology: Course

  1. Initial: Long asymptomatic latent period
  2. Course
    1. Aortic Stenosis gradually progresses to restrict the aortic valve opening
    2. Increased Left Ventricular Outflow Obstruction and flow restriction with increased left ventricular pressures
    3. Next: Concentric Left Ventricular Hypertrophy (left ventricular wall thickening with preserved LV volume)
    4. Next: Diastolic Dysfunction (resistance to LV filling with preserved systolic function)
    5. Next: Systolic Dysfunction and Congestive Heart Failure
    6. Next: Increased myocardial oxygen demand, Coronary Artery compression and secondary Angina
    7. Next: Hypotension and Syncope in response to Exercise

V. Risk Factors

  1. Age >65 years old
  2. Male gender
  3. Bicuspid aortic valve (affects 1-2% of U.S. population)
  4. Other specific valvular conditions (see causes above)
    1. Rheumatic Fever
    2. Subacute Bacterial Endocarditis
  5. Cardiovascular disease and associated risk factors
    1. Hypertension (Hazard Ratio 1.7 for severe Aortic Stenosis)
    2. Diabetes Mellitus (Hazard Ratio 1.5 for severe Aortic Stenosis)
    3. Tobacco Abuse
    4. Hyperlipidemia (Hazard Ratio 1.2 for severe Aortic Stenosis)
    5. Lipoprotein-A or Lp(a) level elevated (genetic factor; Odds Ratio 1.2 for Aortic Stenosis)
  6. Miscellaneous
    1. Thoracic radiation history
    2. Rheumatologic Conditions (e.g. SLE, RA)
  7. References
    1. Yan (2017) J Am Coll Cardiol 69(12): 1523-32 [PubMed]
    2. Yu (2023) Eur Heart J 44(21): 1927-39 [PubMed]

VI. Symptoms

  1. Mild to Moderate stenosis
    1. Asymptomatic for a long latent period while stenosis progresses
    2. More subtle symptoms may go unrecognized
      1. Fatigue
      2. Exercise intolerance
      3. Light Headedness
    3. May present when unmasked by acute comorbidity that exacerbates occult Aortic Stenosis
      1. Atrial Fibrillation with Rapid Ventricular Rate
      2. Decompensated Heart Failure
  2. Severe Obstruction
    1. Dyspnea (most common presenting symptom)
      1. Dyspnea on exertion progresses to Dyspnea at rest
    2. Other presenting symptoms
      1. Presyncope or Syncope
      2. Exercise induced Angina
      3. Congestive Heart Failure

VII. Signs

  1. Precautions
    1. Lack of cardiac murmur has an 88% Negative Predictive Value for significant valvular disease
    2. Exam is otherwise unreliable in detecting valvular heart disease (compared with Echocardiography)
      1. Test Sensitivity: 44%
      2. Test Specificity: 69%
    3. References
      1. Gardezi (2018) Heart 104(22): 1832-35 [PubMed]
  2. Classic Murmur
    1. Harsh, late-peaking, crescendo-decrescendo Systolic Murmur
    2. Medium pitch
    3. Heard best at right upper Sternum (second intercostal space)
    4. May also be heard at apex (esp. elderly)
    5. May radiate into bilateral Carotid Artery region (LR+ 12)
  3. Mild Aortic Stenosis
    1. Loud ejection click (best heard at apex)
    2. Short, early Systolic Murmur (at right second intercostal space)
    3. Loud A2 heart sound (best heard at aortic area)
  4. Moderate Aortic Stenosis
    1. Ejection click (best heard at apex)
    2. Early Systolic Murmur (loudest at right second intercostal space)
      1. Transmitted to Supraclavicular, Carotids, Apex
      2. Harsh
      3. Systolic ejection murmur that peaks later in systole
      4. Ends well before A2 heart sound
    3. Arterial Pulse altered
      1. Upstroke of the pulse has shudder
      2. Delayed, prolonged, low-volume carotid pulsation (Pulsus parvus et tardus)
        1. Test Sensitivity 70% and Test Specificity 98% in Aortic Stenosis
        2. Roldan (1996) Am J Cardiol 77(15): 1327-31 [PubMed]
    4. Apex impulse may be abnormal, accentuated
      1. Slightly sustained
      2. Presystolic Shoulder ("a wave") precedes major systolic impulse
    5. Systolic thrill may be palpated at base
    6. S4 Gallup Rhythm
  5. Severe Aortic Stenosis
    1. Ejection click NO longer present
    2. A2 heart sound is markedly diminished or inaudible (LR+ 15.7)
    3. Systolic Murmur
      1. Variable loudness (may be quiet despite severity)
      2. Long, nearly holosystolic
      3. Harsh (especially at aortic area)
    4. Carotid Pulse very abnormal, with a delayed upstroke (LR+ 6.3)
      1. Very slow and long upstroke (Pulsus parvus et tardus)
      2. Overall very weak pulse
    5. Brachioradial delay
      1. Right Brachial Pulse and right Radial Pulse are simultaneously palpated
      2. Radial Pulse is felt after the Brachial Pulse in severe Aortic Stenosis (also in MR with severe CHF)
        1. Leach (1990) Lancet 335(8699):1199-201 [PubMed]
    6. Apical impulse abnormal
      1. Strong and sustained for all of systole

VIII. Signs: Most significant findings

  1. Precautions
    1. Pulse changes may be masked by atherosclerosis or Hypertension
    2. Murmur may be less prominent with reduced LV function
    3. Murmur may radiate to apex but not carotids in elderly
  2. High Positive Likelihood Ratio (rule-in diagnosis)
    1. Pulsus parvus et tardus (low pulse volume and slow rate of rise of carotid or Brachial Pulse)
  3. Low Negative Likelihood Ratio (most likely to rule-out diagnosis)
    1. Absence of late peaking murmur (early peaking murmur is typically benign)
    2. Lack of radiation to right carotid or clavicle
    3. Normally split Second Heart Sound (S2)

IX. Differential Diagnosis

  1. See Heart Murmur
  2. See Dyspnea Causes
  3. See Syncope
  4. Supravalvular Aortic Stenosis
  5. Membranous supravalvular Aortic Stenosis
  6. Hypertrophic Cardiomyopathy (IHSS)
  7. Mitral Regurgitation

X. Associated Conditions

  1. Atrial Fibrillation (17% of Aortic Stenosis patients)
  2. Coronary Artery Disease (24 to 68% of Aortic Stenosis)
  3. Heyde Syndrome
    1. Rare Coagulopathy resulting from acquired Von Willebrand Disease
    2. Von Willebrand Factor (VVWF) is fragmented by Aortic Stenosis, resulting in VWF Deficiency
    3. Presents with Gastrointestinal Bleeding and an Aortic Stenosis murmur
    4. Coagulopathy improves with aortic Valve Replacement
  4. Bicuspid aortic valve associated conditions
    1. Aortic Root Dilation
    2. Aortic Dissection
    3. AV Node Block

XI. Diagnotics: Electrocardiogram

  1. Precautions
    1. Electrocardiogram may only be abnormal in moderate to severe Aortic Stenosis
  2. Common findings
    1. Left atrial enlargement
    2. Left Ventricular Hypertrophy
      1. Peak systolic gradient (PSG) has been correlated to the QRS amplitude (LVH criteria)
      2. Kishore (1990) Indian Heart J 42(1): 62-5 [PubMed]
  3. Other findings
    1. T Wave reduction in leads I, avL, V5, V6
    2. Left Anterior Hemiblock or Left Bundle Branch Block
    3. Complete AV Block

XII. Imaging

  1. Chest XRay
    1. Precautions
      1. Chest XRay is a low yield test in Aortic Stenosis diagnosis
      2. Chest XRay is primarily used to evaluate presenting symptoms (Dyspnea, Syncope, Chest Pain)
    2. Findings (unreliable)
      1. Apical Contour abnormal suggests large left ventricle
      2. Prominent ascending aorta
      3. Aortic valve calcification
      4. Left Ventricular Hypertrophy may appear as a boot-shaped heart
  2. Echocardiogram
    1. Most important study in the evaluation of suspected Aortic Stenosis
    2. Frequency
      1. Initial presentation
      2. Once Aortic Stenosis is diagnosed, repeat echo per monitoring schedule based on severity (see below)
    3. Indications
      1. Loud (grade 3), unexplained Systolic Murmur (esp. holosystolic, late systolic)
      2. Single Second Heart Sound
      3. History of bicuspid aortic valve
      4. Symptoms suggestive of Aortic Stenosis
      5. New murmur associated with new symptom presentation (Dyspnea, Syncope, Angina)
    4. Findings
      1. Aortic Stenosis diagnosis
        1. Aortic Stenosis grading with aortic valve gradient, orifice size, jet velocity (see classification above)
          1. Aortic valve thick and sclerotic (bright white) with poor excursion on PLAX View
          2. Continuous Wave Doppler (CWD) at aortic valve with jet velocity measured in A5C View
        2. Aortic Stenosis complications (LV hypertrophy, Diastolic Dysfunction, Systolic Dysfunction)
          1. LV septum and free wall thickened on apical 4 chamber and PLAX Views
          2. Left atrial dilation to more than a third of the cardiac diameter on PLAX View
      2. Other aortic valve disorders
        1. Bicuspid aortic valve
        2. Mildly obstructed valve
        3. Thickened, sclerotic valve (aortic sclerosis)
      3. Other valve disorders presenting similarly to Aortic Stenosis (Dyspnea, Syncope, Angina)
        1. Acute Mitral Regurgitation
          1. May be seen with Myocardial Infarction with papillary Muscle rupture
          2. Chronic Mitral Regurgitation may be associated with Aortic Stenosis (worse prognosis)
        2. Prosthetic valve disorders (e.g. valvular regurgitation or obstruction)
  3. Cardiac Catheterization (Angiogram)
    1. Can directly measure left ventricular pressure gradient

XIII. Classification: Aortic Stenosis Severity (by Echocardiogram)

  1. Aortic valve area (AVA in cm2)
    1. Normal: 3 to 4 cm2
    2. Mild: 1.5 to 2 cm2
    3. Moderate: 1 to 1.5 cm2
    4. Severe: <1 cm2
    5. Critical: <0.8 cm2
    6. Low Flare, Low Gradient Severe Aortic Stenosis <1 cm2
      1. But Vmax <4 m/sec and mAVPG <40 mmHg due to HFrEF with decreased Stroke Volume
  2. Maximum Aortic jet velocity (Vmax in m/sec, transaortic valve velocity)
    1. Normal: <2.0 m/sec
    2. Mild: 2.0 to 2.9 m/sec
    3. Moderate: 3.0 to 3.9 m/sec
    4. Severe: >4.0 m/sec
  3. Mean Aortic Valve Pressure Gradient (mAVPG in mmHg)
    1. Normal: <10 mmHg
    2. Mild: 10-20 mmHg
    3. Moderate: 20-40 mmHg
    4. Severe: >40 mmHg
    5. Critical: >50 mmHg

XIV. Management: General Measures

  1. Asymptomatic Aortic Stenosis progression is not prevented by any specific measures
  2. SBE Prophylaxis is no longer recommended (until aortic Valve Replacement, or history of prior endocarditis)
  3. Manage comorbid conditions
  4. Maintain adequate hydration (Preload dependent)
  5. Avoid strenuous Exercise or activity in moderate to severe Aortic Stenosis
    1. Limit activity in high Dynamic Sports and high Static Sports
    2. No restriction needed for mild Aortic Stenosis
  6. Control Hypertension (40% of patients)
    1. Uncontrolled Hypertension in Aortic Stenosis is associated with increased mortality
    2. Start medications at low dose and titrate slowly, avoiding vasodilation and Syncope risk
    3. First-Line Medications
      1. Angiotensin Receptor Blockers or ACE Inhibitors
      2. Amlodipine (Norvasc)
    4. Other Medications to use with caution or to avoid
      1. Diuretics (slowly titrate from low dose)
      2. Avoid peripheral alpha blockers (risk of Syncope)
  7. Manage comorbid Atrial Fibrillation (5% of patients) with rate control
    1. See Atrial Fibrillation Rate Control
    2. Use with caution Beta Blockers and Calcium Channel Blockers
      1. Risk of exacerbating Left Ventricular Systolic Dysfunction
  8. Reduce other Cardiovascular Risk
    1. See Cardiac Risk Management
    2. Tobacco Cessation
    3. Consider Aspirin prophylaxis
    4. Consider Statin for lipid lowering
      1. Statins do not reduce aortic valve calcification or stenosis
        1. Cowell (2005) N Engl J Med 352(23): 2389-97 [PubMed]
      2. However, Statins do reduce overall Cardiovascular Risk
        1. Use 10 year Cardiac Risk calculators (e.g. PREVENT) for indications and dosing
  9. Monitoring: Echocardiogram Frequency
    1. Mild Aortic Stenosis: Every 3-5 years
    2. Moderate Aortic Stenosis: Every 1-2 years
    3. Severe Aortic Stenosis: Every 6-12 months

XV. Management: Aortic Stenosis Staging-Based

  1. Stage A: Aortic Stenosis Risk Factors (but no current Aortic Stenosis)
    1. Risk factor reduction (see above)
  2. Stage B: Progressive Mild Aortic Stenosis (asymptomatic)
    1. Repeat Echocardiogram every 3-5 years
    2. No Exercise restriction
  3. Stage B: Progressive Moderate Aortic Stenosis (asymptomatic)
    1. Repeat Echocardiogram every 1-2 years
    2. Avoid strenuous Exercise (including high Dynamic Sports, high Static Sports)
  4. Stage C: Asymptomatic Severe Aortic Stenosis
    1. Cardiology referral
    2. Avoid strenuous Exercise or activity
    3. Repeat Echocardiogram every 6-12 months
    4. Aortic Valve Replacement indications (see below)
      1. Left Ventricular Ejection Fraction <50%
      2. Other cardiovascular surgery needed
      3. Maximum Aortic jet velocity (Vmax): >5 m/sec (or increases >0.3 m/sec in 1 year on serial echo)
      4. Positive Exercise Stress Test
  5. Stage D: Symptomatic Severe Aortic Stenosis (e.g. exertional Dyspnea, Syncope, Heart Failure)
    1. See below for acute management
    2. Prompt cardiology referral for aortic Valve Replacement

XVI. Management: Symptomatic and severe, Critical Aortic Stenosis (>40 mmHg across valve or aortic jet velocity >4.0 m/s)

  1. Admit symptomatic severe Aortic Stenosis and plan aortic Valve Replacement
  2. Consult Cardiothoracic surgery and interventional cardiology
    1. Consider valvuloplasty as a temporizing measure in Unstable Patients
  3. Maintain euvolemia with hydration
    1. Aortic Stenosis is a Preload dependent disorder
  4. Maintain normal Heart Rate
    1. Tachycardia and Bradycardia are poorly tolerated
  5. Approach: Hypertension
    1. See SCAPE management below
    2. Preferred agents
      1. ACE Inhibitors
      2. Amlodipine (Norvasc)
      3. Nitroprusside
        1. Consider in Critical Aortic Stenosis and ejection fraction <35%
        2. Khot (2003) N Engl J Med 348(18): 1756-63 [PubMed]
    3. Agents to use with caution
      1. Diuretics
        1. Indicated for Congestive Heart Failure with hypervolemia
        2. Use with caution (lowers LV filling pressure)
      2. Use Nitroglycerin only with caution
        1. Indicated for Congestive Heart Failure with hypervolemia
        2. Monitor Blood Pressure carefully
        3. Volume expansion may be required
      3. Use Beta Blockers with caution
        1. Indicated for rate control in Supraventricular Tachycardia
        2. Risk of Congestive Heart Failure
    4. Agents to avoid
      1. Peripheral Alpha Adrenergic Antagonists
  6. Approach: Hypervolemia (CHF)
    1. Nitroglycerin and Diuretics may be used, but monitor closely for Hypotension
    2. In Critical Illness, may require ECMO or intraortic balloon bridging to aortic Valve Replacement
  7. Approach: Hypovolemia
    1. Hypotension is high risk in Aortic Stenosis
      1. MAP below 65 mmHg decreases coronary perfusion and decreases Cardiac Function
    2. May administer small fluid boluses in cycles with reassessment after each bolus
      1. HIgh risk for Fluid Overload (fine balance)
      2. Employ Vasopressors early
      3. Follow Point Of Care Cardiac Ultrasound (Cardiac Function, inferior vena cava)
    3. Vasopressors (Phenylephrine, Vasopressin, Norepinephrine)
      1. Administer at lowest effective dose for shortest period
      2. Vasopressors that do not effect Heart Rate are preferred (unless concurrent Bradycardia)
        1. Vasopressin and Phenylephrine constrict Afterload and improve Coronary Artery filling
      3. Start Vasopressin 0.04 units/min
      4. Add Phenylephrine or Norepinephrine as needed
        1. Alternatively, may increase Vasopressin to 0.06 units/min if used as single Vasopressor
  8. Approach: Sympathetic Crashing Acute Pulmonary Edema (SCAPE)
    1. Fentanyl may suppress sympathetic overdrive
    2. Noninvasive Ventilation (CPAP)
    3. Consider vasodilators for Afterload reduction with caution
      1. Clevidapine
        1. Preferred for rapid on and off activity (contrast with longer acting Nicardipine)
          1. Able to be rapidly turned off in case of Hypotension
        2. Preferred for maintained Preload (contrast with venodilation with Nitroglycerin)
  9. Approach: Advanced Airway
    1. Start with Noninvasive Ventilation (CPAP)
      1. Use Fentanyl as needed to facilitate patient comfort with CPAP
      2. May be sufficient Ventilatory management to avert Mechanical Ventilation
    2. Endotracheal Intubation
      1. Attempt Dissociative Awake Intubation or Awake Nasotracheal Intubation
      2. Use Ketamine for induction agent
      3. Avoid Paralytic Agent (loss of sympathetic drive and apnea)
  10. References
    1. Weingart and Swaminathan in Swadron (2022) EM:Rap 22(3): 2-4

XVII. Management: Aortic Valve Replacement

  1. Precautions
    1. Aortic valve area (AVA) <1 cm2 is criteria for stenosis unless completely normal cardiovascular testing
    2. In HFrEF, Stroke Volume is reduced, resulting in less severe Vmax (<4 m/sec) and mAVPG (<40 mmHg)
      1. However, aortic valve area will still be severely reduced at <1 cm2
      2. Known as Low Flare, Low Gradient Severe Aortic Stenosis
    3. Surgical evaluation should be prompt for severe Aortic Stenosis
      1. Do not Exercise Stress Test severe Aortic Stenosis with symptoms (high risk for adverse events)
        1. Consider stress test only if symptomatic status is unclear
      2. Severe Aortic Stenosis is a risk for sudden death
      3. Valve Replacement may be indicated even if ejection fraction low
      4. Valve Replacement is not effective if low ejection fraction and low valve gradient
      5. Carabello (2002) N Engl J Med 346:677-82 [PubMed]
  2. Indications for Aortic Valve Replacement
    1. Criteria 1: Severe Aortic Stenosis (see classification above) and
      1. Maximum Aortic jet velocity (Vmax): >4 m/sec
      2. Mean gradient: >40 mmHg
      3. Aortic valve area: <1 cm2
    2. Criteria 2: One of criteria below
      1. Symptomatic Aortic Stenosis
      2. Possible symptomatic Aortic Stenosis (esp. elderly) with abnormal stress test
        1. Symptoms or Hypotension
          1. Left Ventricular ejection fraction <50%
        2. Dobutamine Stress Echo with <=1 cm valve area or aortic jet velocity >=4 m/s
      3. Heart Surgery (e.g. CABG) is already planned (consider AVR even if moderate Aortic Stenosis)
      4. Left ventricular ejection fraction <50%
      5. Severe aortic valve calcification or rapid progression (e.g. 0.3 m/s increase per year)
        1. Low-flow, low gradient severe Aortic Stenosis may initially be misdiagnosed as moderate Aortic Stenosis
        2. Most common in older women with Hypertension
        3. However Aortic valve area (AVA) will be<1 cm2
      6. Asymptomatic but near Critical Aortic Stenosis
        1. Aortic valve gradient >60 mmHg
        2. Aortic valve orifice <0.6 cm2
        3. Aortic jet velocity >5.0 m/s
        4. Nishimura (2005) Mayo Reviews Lecture, Rochester
  3. Aortic Valve Replacement Types
    1. Transcatheter Aortic Valve Replacement (TAVR)
      1. Catheter deployed collapsible metal mesh frame coated in cow or pig heart tissue
      2. Requires initial Warfarin (INR target 2-3) or DOAC for 3-6 months, then lifelong Aspirin 81 mg orally daily
      3. Consider with age >65 years or Life Expectancy <20 years (otherwise open surgical replacement is preferred)
      4. Efficacy and safety
        1. Averts the risks of major open thoracic surgery (Atrial Fibrillation, severe bleeding)
        2. Associated with higher vascular complications, Pacemaker requirement and reintervention requirement
        3. Similar short and longterm mortality as with standard open Valve Replacement
          1. Caminiti (2024) Am J Cardiol 230:6-13 [PubMed]
        4. Similar outcomes for bicuspid aortic valve as with standard open Valve Replacement
          1. Saeed Al-Asad (2023) Am J Cardiol 203:105-12 [PubMed]
    2. Bioprosthetic Aortic Valve Replacement
      1. Open thoracic surgery with pig, cow or human cadaver donor valve
      2. Requires initial Warfarin for 3-6 months (INR target 2-3), then lifelong Aspirin 81 mg orally daily
    3. Mechanical Aortic Valve Replacement
      1. Open thoracic surgery with valves made of durable pyrolytic carbon/titanium wrapped in fabric (e.g. polyester)
      2. Requires lifelong Warfarin
        1. Target INR 2-3 if no additional risk factors indicating higher target range
        2. Target INR 2.5 to 3.5 Risk Factor Indications
          1. Atrial Fibrillation
          2. Known Hypercoagulable state OR history of prior Venous Thromboembolism
          3. Left Ventricular Systolic Dysfunction (HFrEF)
  4. Post-Valve Replacement
    1. Anticoagulation (based on Aortic Valve Replacement Type)
    2. SBE Prophylaxis

XVIII. Complications

  1. Left Ventricular Hypertrophy
  2. Congestive Heart Failure
  3. Exacerbation of Coronary Artery Disease
  4. Sudden Death

XIX. Prognosis: Prior to Valve Replacement

  1. Mild Aortic Stenosis: Good (slow progression)
    1. Anticipate active and asymptomatic for 10-50 years
  2. Asymptomatic severe Aortic Stenosis
    1. At 5 years, 72% will die or have symptoms
    2. Recent data suggests sudden death rate is high
    3. Pellikka (2005) Circulation 111:3290-5 [PubMed]
  3. Symptomatic severe Aortic Stenosis: Poor prognosis
    1. Most patients will have symptom progression
    2. Anticipate death within 3 years in most patients
    3. Even mild pre-AVR symptoms predict a 2 year mortality >50%

XX. Prognosis: After Aortic Valve Replacement

  1. Consider transcatheter Valve Replacement (TAVR) in those who are at very high surgical risk
  2. Mortality at 30 days post-AVR: 3% (up to 4.5% if CABG performed at the same time)

XXI. Resources

  1. Late Aortic Stenosis (University of Washington School of Medicine)
    1. https://depts.washington.edu/physdx/audio/lateas.mp3

XXII. References

  1. Kondos (1998) CMEA Medicine Review Lecture, San Diego
  2. Long and Gottlieb in Herbert (2022) EM:Rap 22(2): 13-5
  3. Schauer et al. (2016) Crit Dec Emerg Med 30(9):13-9
  4. Assi (1998) Postgrad Med 104(6):99-110 [PubMed]
  5. Bonow (1998) Circulation 98:1949-84 [PubMed]
  6. Bonow (2006) Circulation 114(5): e84-e231 [PubMed]
  7. Carabello (1997) N Engl J Med 337(1):32-41 [PubMed]
  8. Gottlieb (2018) J Emerg Med 55(1): 34-41 [PubMed]
  9. Grimard (2016) Am Fam Physician 93(5): 371-8 [PubMed]
  10. Grimard (2008) Am Fam Physician 78(6): 717-25 [PubMed]
  11. Lester (1998) Chest 113:1109-14 [PubMed]
  12. Otto (2006) J Am Coll Cardiol 47(11): 2141-51 [PubMed]
  13. Patel (2026) Am Fam Physician 114(2): 148-55 [PubMed]
  14. Shipton (2001) Am Fam Physician 63(11):2201-8 [PubMed]

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