Aortic Valve Stenosis (AS)

What is Aortic Valve Stenosis (AS) according to the summary?

A valvular heart disease characterized by narrowing of the aortic valve, obstructing blood outflow from the left ventricle into the aorta. Summary 1

What is the primary consequence of obstructed blood flow in Aortic Stenosis (AS) on the left ventricle?

It leads to chronic and progressive excess load on the left ventricle and potentially left ventricular failure. Summary 2

What are the classic symptoms that develop when Aortic Stenosis (AS) becomes symptomatic?

Dyspnea on exertion, angina pectoris, or syncope. Summary 3

What is the characteristic murmur of Aortic Stenosis (AS) mentioned in the summary?

A harsh, crescendo-decrescendo murmur in systole that radiates to the carotids. Summary 4

What is the noninvasive gold standard for diagnosing Aortic Stenosis (AS) according to the summary?

Echocardiography is the noninvasive gold standard for diagnosis. Summary 5

How are symptomatic patients or those with severe Aortic Stenosis (AS) definitively treated?

They require immediate aortic valve replacement (AVR) as definitive treatment. Summary 6

What are the valve replacement options for severe Aortic Stenosis (AS) mentioned in the summary?

Options include surgical AVR (SAVR) or transcatheter AVR (TAVR) for patients with high operative risk. Summary 7

What acute complications are patients with severe Aortic Stenosis (AS) at high risk of developing?

High risk of acute heart failure and cardiogenic shock. Summary 8

What is the most common valvular heart disease in industrialized countries?

Aortic stenosis (AS). Epidemiology 9

With what other aortic valve condition is Aortic Stenosis (AS) frequently associated?

Aortic regurgitation. Epidemiology 10

How does the prevalence of Aortic Stenosis (AS) change with age?

Prevalence increases with age, reaching up to 12.4% among individuals ≥ 75 years. Epidemiology 11

What is the most common cause of valvular Aortic Stenosis (AS)?

Aortic valve sclerosis (calcification and fibrosis of aortic valve leaflets). Etiology 12

What congenital condition commonly predisposes younger individuals to Aortic Stenosis (AS)?

Bicuspid aortic valve (BAV), the most common congenital heart valve malformation. Etiology 13

How does Bicuspid Aortic Valve (BAV) lead to Aortic Stenosis (AS)?

BAV predisposes the valve to dystrophic calcification and degeneration, leading to earlier onset of AS symptoms compared to typical age-related calcification. Etiology 14

What infectious condition, now rare in high-income countries, can cause Aortic Stenosis (AS)?

Rheumatic fever, which causes stenosis via commissural fusion. Etiology 15

What is the primary hemodynamic consequence of a narrowed aortic valve opening during systole?

Obstruction of blood flow from the left ventricle (LV), leading to increased LV pressure. Pathophysiology 16

What type of hypertrophy does the left ventricle undergo in response to Aortic Stenosis (AS)?

Left ventricular concentric hypertrophy. Pathophysiology 17

What are the consequences of left ventricular concentric hypertrophy in Aortic Stenosis (AS)?

Increased LV oxygen demand, impaired diastolic filling (leading to left heart failure), and reduced coronary flow reserve. Pathophysiology 18

How does severe Aortic Stenosis (AS) eventually affect the right heart?

Decreased LV distensibility reduces cardiac output → backflow into pulmonary circulation → higher pulmonary pressure (afterload) on the right heart → right heart failure. Pathophysiology 19

For how long can Aortic Stenosis (AS) remain asymptomatic?

Aortic stenosis may remain asymptomatic for years, particularly with mild or moderate stenosis. Clinical Features 20

What are the three cardinal symptoms of Aortic Stenosis (AS)? (Use the mnemonic "SAD")

Syncope, Angina pectoris, and Dyspnea (typically exertional). Clinical Features 21

What physical exam finding related to the pulse is characteristic of Aortic Stenosis (AS)?

A weak and delayed distal pulse (pulsus parvus et tardus). Clinical Features 22

What palpable finding might be present over the carotids or aorta in Aortic Stenosis (AS)?

A palpable systolic thrill. Clinical Features 23

Describe the classic murmur of Aortic Stenosis (AS).

Harsh crescendo-decrescendo (diamond-shaped), late systolic ejection murmur radiating bilaterally to the carotids, best heard in the 2nd right intercostal space. Clinical Features 24

How does handgrip affect the intensity of the Aortic Stenosis (AS) murmur?

Handgrip decreases the intensity of the murmur (by increasing afterload). Clinical Features 25

How do Valsalva and standing from squatting affect the Aortic Stenosis (AS) murmur?

Valsalva and standing decrease or do not change the intensity (helps differentiate from HOCM, which increases). Clinical Features 26

What heart sounds (besides the murmur) are associated with Aortic Stenosis (AS)?

A soft S2 sound, an S4 gallop (heard best at the apex), and possibly an early systolic ejection click. Clinical Features 27

What is the American Heart Association (AHA)/American College of Cardiology (ACC) staging system for AS based on?

Based on echocardiographic criteria of valve anatomy and hemodynamics (e.g., AVA, mean gradient). Classification 28

What is the Aortic Valve Area (AVA) range for mild progressive Aortic Stenosis (Stage B)?

Mild: 1.5-2.9 cm². Classification 29

What is the Aortic Valve Area (AVA) range for moderate progressive Aortic Stenosis (Stage B)?

Moderate: 1.0-1.4 cm². Classification 30

What Aortic Valve Area (AVA) defines severe Aortic Stenosis (Stage C/D)?

≤ 1.0 cm². Classification 31

What mean aortic pressure gradient defines severe Aortic Stenosis (Stage C/D)?

≥ 40 mm Hg. Classification 32

What differentiates Stage C1 from Stage C2 severe Aortic Stenosis (AS)?

Stage C1 is asymptomatic severe AS with normal LVEF. Stage C2 is asymptomatic severe AS with LV dysfunction (LVEF < 50%). Classification 33

What defines Stage D Aortic Stenosis (AS)?

Symptomatic severe AS. Classification 34

What is the recommended primary test and noninvasive gold standard for diagnosing and assessing Aortic Stenosis (AS)?

Transthoracic echocardiography (TTE). Diagnosis 35

What key findings on echocardiography support an Aortic Stenosis (AS) diagnosis?

Calcification and narrowing of the aortic valve, increased mean aortic pressure gradient and transvalvular velocity, signs of cardiac remodeling (concentric LVH). Diagnosis 36

What ECG findings suggest left ventricular hypertrophy secondary to Aortic Stenosis (AS)?

Positive voltage criteria (e.g., Sokolow-Lyon index); may also see nonspecific ST-segment and T-wave abnormalities. Diagnosis 37

What findings on chest x-ray might be seen in Aortic Stenosis (AS)?

Visible aortic valve calcifications, x-ray signs of LVH, pulmonary congestion (if HF present), or poststenotic dilation of the aorta. Diagnosis 38

When is diagnostic cardiac catheterization considered for Aortic Stenosis (AS)?

Consider in symptomatic patients with inconclusive noninvasive testing or discrepancy between symptoms and noninvasive testing results. (Not routinely indicated). Diagnosis 39

What is the definitive treatment for symptomatic and/or severe Aortic Stenosis (AS)?

Aortic valve replacement (AVR) or repair. Treatment 40

How are patients with asymptomatic or mild-to-moderate Aortic Stenosis (AS) typically managed?

Usually treated conservatively with monitoring (serial echo), management of comorbidities (HTN, DM), and IE prophylaxis if indicated. Treatment 41

When is surgical AVR (SAVR) generally recommended over TAVR?

Generally recommended for patients age < 65 years, life expectancy > 20 years, or those with low to moderate surgical risk. Treatment 42

When is transcatheter AVR (TAVR) generally recommended over SAVR?

Generally recommended for patients age > 80 years, life expectancy < 10 years, or those with high or prohibitive surgical risk (predicted survival > 12 months). Treatment 43

What role does percutaneous balloon valvuloplasty have in treating adult Aortic Stenosis (AS)?

Limited role in older patients; may be used in children, adolescents, and young adults, or as a bridge to AVR in unstable patients. Treatment 44

What are the most critical acute complications of severe Aortic Stenosis (AS)?

Cardiogenic shock and acute heart failure (AHF). Atrial fibrillation with rapid ventricular response can also lead to rapid decompensation. Complications 45

What is the prognosis for asymptomatic patients with Aortic Stenosis (AS)?

Mortality rate is < 1% per year. Prognosis 46

What is the prognosis for symptomatic patients with Aortic Stenosis (AS) if left untreated?

Mortality rate in the first 2 years is > 50%. Prognosis 47

Among symptomatic AS patients, which symptom carries the worst prognosis?

Symptoms of heart failure carry the worst prognosis, followed by syncope, then angina pectoris. Prognosis 48