AORTIC STENOSIS

A Review for the Internist,Hospitalist,

and Family Physician

R.B.Whiting,MD,MACP,FACC
CD
 VALVULAR AORTIC STENOSIS

Congenital
Acquired
Rheumatic
Degenerative(age related)
Atherosclerotic
Calcific AS associated with Paget’s Disease,
end-stage renal failure, rheumatoid arthritis,
etc.

•
 AORTIC SCLEROSIS

• Irregular thickening of the valve leaflets seen on

• echo but without significant obstruction. May
• result in a systolic ejection murmur.

• Approx. 25% over age 65 and over 40% over 85

• Evidence suggests Ao sclerosis does progress to
• degenerative aortic stenosis.
•
 AORTIC SCLEROSIS
• Cosmi et al studied 2000 pts with aortic
• sclerosis and found 16% progressed to
• aortic stenosis and 10% had mild, 3%
moderate, and 2% severe obstruction.
The average time for progression from
ao sclerosis to severe stenosis was
8 years.
Arch Int Med 2002; 62:2345
 Degenerative Aortic Stenosis
• Most common type of AS today and the
usual cause for aortic valve replacement
• Shares common risk factors with mitral
annular calcification
• Risk factors for calcific aortic stenosis are
similar to those for vascular
atherosclerosis
 AORTIC STENOSIS
• NATURAL HISTORY
• May be asymptomatic for many years
• Gradual onset and slow progression
• LVH allows large gradient to be
• tolerated for years with little or no
• reduction of cardiac output, left
• ventricular dilatation, or symptoms
 AORTIC STENOSIS
• Obstruction is progressive-but insidious

• Rate of progression is variable so difficult to

• predict in an individual patient

On average: AVA decreases 0.12 cm2/yr

• with average increase jet velocity of
• 0.32 m/sec per year and mean gradient
• increase of 7 mm Hg per year
•
 AORTIC STENOSIS

• Critical obstruction is associated with:

• Peak gradient >50 mm Hg in presence

• of normal output
• Effective oriface area <0.8 cm2

• Normal ao valve area=2.6-3.5 cm2

 AORTIC STENOSIS

• In general:

• Mild Aortic Stenosis=1.5-2.0 cm2

• Moderate Stenosis=1-1.5 cm2
• Severe Aortic Stenosis=<1.0 cm2
• Critical Aortic Stenosis=<0.8 cm2
 AORTIC STENOSIS
• Thickening and stiffening of the LV in the
face of increasing obstruction results in
• Increased LVEDP
• Result=LAH and diastolic dysfunction
• Left atrium becomes critical in filling the
• ventricle and At Fib or AV dissociation
• are poorly tolerated
 AORTIC STENOSIS
• In significant ao stenosis, the cardiac
• output may be fairly well maintained at
• rest but fails to augment with exercise
• Late in the course of severe AS : cardiac
• output, stroke volume, and the gradient
• itself all decline……while the
• Mean LA pressure, capillary wedge
• pressure and P.A. pressure increase
 AORTIC STENOSIS
• DIAGNOSIS:
• Symptoms
• Physical exam
• Chest X-Ray
• EKG
• Echo-major diagnostic tool and means
• of follow-up. Allows measurement of
• gradient, LV function, associated lesions
 AORTIC STENOSIS
• Symptoms:
• Can be asymptomatic
• Dyspnea on exertion
• Angina
• Syncope or “light spells”
• Palpitations not listed as major
• symptom, but common in significant
• heart disease
 AORTIC STENOSIS
• Implications of symptoms
• With unrelieved obstruction survival is
• approx 2 years after onset of failure,
• 3 years after onset of syncope, and
• 5 years after onset of angina
• Recent data: symptomatic pts with
• severe stenosis-average survival was
• 2 years with only 20% survival at 5 yrs
 AORTIC STENOSIS
• Physical Exam
• Narrow pulse pressure, slow arterial
• upstroke, carotid shudder
• Sustained PMI and with failure it is
• displaced laterally and inferiorly
• S4 common, S1 soft, S2 may be single,
• systolic ejection murmur best at the
• base
•
 AORTIC STENOSIS
• MANAGEMENT

• Medical: medications and careful

• follow-up

• Surgical: Valve replacement is

• the best approach in most cases
•
 AORTIC STENOSIS
• Medical Management
• Patient education
• Medications-patients with associated
• hypertension or CHF can be treated
• with medications if AS is mild or
• moderate. Caution if Severe AS,
• especially with beta blockers and
• dilator type agents
• Favor use of statin drugs
 AORTIC STENOSIS
• Management-2
• Periodic echo-if mild AS: echo every
• 2 years; for moderate AS every year,
• and for severe AS echo assessment
• every 6-8 months
• Question the role of SBE prophylaxis
 AORTIC STENOSIS
• Management-3 (surgical and related)
• Non-calcified congenital AS can be
• managed with open commissural
• incision at low risk
• Some cases of adult AS can be
• managed by Balloon Valvuloplasty-
• often will need operative care in 2 yrs
• Most adult calcific AS if severe or
• progressive-symptomatic best care is AVR
 AORTIC STENOSIS
• Management-4
• AVA <1.0 cm2 whose symptoms are
• believed to result from the stenosis
• Asymptomatic patients if progressive
• LV dysfunction, or if hypotensive
• response to exercise
• Threshold for AVR will likely lower in
• the future
 AORTIC STENOSIS
• Effects of successful AVR
• Substantial clinical and hemodynamic
• improvement
• Ten year survival approx 85%
• Exertional dyspnea improved as also
• frequency and severity of angina
• Impaired LV performance improves
• toward normal often and LV mass
• decreases toward normal-not normal
 AORTIC STENOSIS
• SUMMARY:
• Aortic stenosis of varying degree is
• common in adults
• Diagnosis and management are
• DEPENDENT on the internist,
• hospitalist, and family physician
• Follow up involves history, physical,
• and especially the echo-Doppler
• Valve replacement=best overall Rx