In aortic stenosis the aortic valve narrows, most often from age-related calcium buildup or a bicuspid valve, and the left ventricle must push harder to eject blood. Patients may feel fine for years, but once chest pain, fainting or heart failure appear, survival drops quickly without valve replacement.
Key symptoms
- Shortness of breath on exertion and less exercise tolerance
- Chest pain on exertion
- Fainting or near fainting with effort
- Fatigue
- Often no symptoms; a murmur found on a routine exam
What you find on exam
- Harsh crescendo-decrescendo systolic murmur at the right upper sternal border, spreading to the carotids
- Weak, delayed carotid upstroke (pulsus parvus et tardus)
- Soft or absent second heart sound in severe disease
- Narrow pulse pressure; signs of heart failure
Tests
- Echocardiogram: valve area, peak velocity and mean gradient
- ECG: left ventricular hypertrophy
- BNP and chest X-ray if heart failure is suspected
- Exercise testing only in patients without symptoms, never in those with symptoms
- Coronary angiography or CT before valve replacement
Treatment basics
- Valve replacement for severe stenosis with symptoms or a low ejection fraction
- Surgical (SAVR) or transcatheter (TAVR) replacement, chosen by age and surgical risk
- Regular echocardiogram follow-up while there are no symptoms
- Treat high blood pressure; use vasodilators such as nitrates with great care
- Avoid hard exertion in severe stenosis
Red flags
- Fainting with exertion
- Chest pain or breathlessness at rest
- Low blood pressure after a vasodilator
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.