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Clinical manifestations and diagnosis of aortic stenosis in adults

Author
Catherine M Otto, MD
Section Editor
William H Gaasch, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC

INTRODUCTION

Aortic valve stenosis is the most common cause of left ventricular outflow obstruction in children and adults; less common causes are subvalvular or supravalvular disease (table 1). This topic will review the clinical features, diagnosis, and evaluation of valvular aortic stenosis (AS) [1].

The pathogenesis, epidemiology, natural history, medical therapy, and percutaneous and surgical valve interventions for AS are discussed separately. (See "Natural history, epidemiology, and prognosis of aortic stenosis" and "Medical management of asymptomatic aortic stenosis in adults" and "Indications for valve replacement in aortic stenosis in adults" and "Choice of prosthetic heart valve for surgical replacement" and "Transcatheter aortic valve implantation: Indications and outcomes" and "Percutaneous balloon aortic valvotomy".)

CLINICAL MANIFESTATIONS

Symptoms — The classic clinical manifestations of aortic stenosis (AS) are heart failure (HF), syncope, and angina. However, these "classic" manifestations reflect end-stage disease. Now, with earlier diagnosis by echocardiography and prospective followup of patients, the following are the most common presenting symptoms (see early symptoms in (figure 1)):

Dyspnea on exertion or decreased exercise tolerance

Exertional dizziness (presyncope) or syncope

                                 

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Literature review current through: Nov 2016. | This topic last updated: Mon Oct 24 00:00:00 GMT 2016.
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References
Top
  1. Lindman BR, Clavel MA, Mathieu P, et al. Calcific aortic stenosis. Nat Rev Dis Primers 2016; 2:16006.
  2. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
  3. Green SJ, Pizzarello RA, Padmanabhan VT, et al. Relation of angina pectoris to coronary artery disease in aortic valve stenosis. Am J Cardiol 1985; 55:1063.
  4. Vandeplas A, Willems JL, Piessens J, De Geest H. Frequency of angina pectoris and coronary artery disease in severe isolated valvular aortic stenosis. Am J Cardiol 1988; 62:117.
  5. Silaruks S, Clark D, Thinkhamrop B, et al. Angina pectoris and coronary artery disease in severe isolated valvular aortic stenosis. Heart Lung Circ 2001; 10:14.
  6. Julius BK, Spillmann M, Vassalli G, et al. Angina pectoris in patients with aortic stenosis and normal coronary arteries. Mechanisms and pathophysiological concepts. Circulation 1997; 95:892.
  7. Davies JE, Sen S, Broyd C, et al. Arterial pulse wave dynamics after percutaneous aortic valve replacement: fall in coronary diastolic suction with increasing heart rate as a basis for angina symptoms in aortic stenosis. Circulation 2011; 124:1565.
  8. Munt B, Legget ME, Kraft CD, et al. Physical examination in valvular aortic stenosis: correlation with stenosis severity and prediction of clinical outcome. Am Heart J 1999; 137:298.
  9. Etchells E, Bell C, Robb K. Does this patient have an abnormal systolic murmur? JAMA 1997; 277:564.
  10. Etchells E, Glenns V, Shadowitz S, et al. A bedside clinical prediction rule for detecting moderate or severe aortic stenosis. J Gen Intern Med 1998; 13:699.
  11. Ozkan A, Kapadia S, Tuzcu M, Marwick TH. Assessment of left ventricular function in aortic stenosis. Nat Rev Cardiol 2011; 8:494.
  12. Faggiano P, Antonini-Canterin F, Ribichini F, et al. Pulmonary artery hypertension in adult patients with symptomatic valvular aortic stenosis. Am J Cardiol 2000; 85:204.
  13. Greve AM, Gerdts E, Boman K, et al. Prognostic importance of atrial fibrillation in asymptomatic aortic stenosis: the Simvastatin and Ezetimibe in Aortic Stenosis study. Int J Cardiol 2013; 166:72.
  14. Bang CN, Greve AM, Boman K, et al. Effect of lipid lowering on new-onset atrial fibrillation in patients with asymptomatic aortic stenosis: the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. Am Heart J 2012; 163:690.
  15. Gerber IL, Stewart RA, Legget ME, et al. Increased plasma natriuretic peptide levels reflect symptom onset in aortic stenosis. Circulation 2003; 107:1884.
  16. Lim P, Monin JL, Monchi M, et al. Predictors of outcome in patients with severe aortic stenosis and normal left ventricular function: role of B-type natriuretic peptide. Eur Heart J 2004; 25:2048.
  17. Weber M, Arnold R, Rau M, et al. Relation of N-terminal pro B-type natriuretic peptide to progression of aortic valve disease. Eur Heart J 2005; 26:1023.
  18. Bergler-Klein J, Klaar U, Heger M, et al. Natriuretic peptides predict symptom-free survival and postoperative outcome in severe aortic stenosis. Circulation 2004; 109:2302.
  19. Clavel MA, Malouf J, Michelena HI, et al. B-type natriuretic peptide clinical activation in aortic stenosis: impact on long-term survival. J Am Coll Cardiol 2014; 63:2016.
  20. Chambers J, Bach D, Dumesnil J, et al. Crossing the aortic valve in severe aortic stenosis: no longer acceptable? J Heart Valve Dis 2004; 13:344.
  21. Omran H, Schmidt H, Hackenbroch M, et al. Silent and apparent cerebral embolism after retrograde catheterisation of the aortic valve in valvular stenosis: a prospective, randomised study. Lancet 2003; 361:1241.
  22. John AS, Dill T, Brandt RR, et al. Magnetic resonance to assess the aortic valve area in aortic stenosis: how does it compare to current diagnostic standards? J Am Coll Cardiol 2003; 42:519.
  23. Friedrich MG, Schulz-Menger J, Poetsch T, et al. Quantification of valvular aortic stenosis by magnetic resonance imaging. Am Heart J 2002; 144:329.
  24. Kilner PJ, Manzara CC, Mohiaddin RH, et al. Magnetic resonance jet velocity mapping in mitral and aortic valve stenosis. Circulation 1993; 87:1239.
  25. Dweck MR, Joshi S, Murigu T, et al. Midwall fibrosis is an independent predictor of mortality in patients with aortic stenosis. J Am Coll Cardiol 2011; 58:1271.
  26. Weidemann F, Herrmann S, Störk S, et al. Impact of myocardial fibrosis in patients with symptomatic severe aortic stenosis. Circulation 2009; 120:577.
  27. Herrmann S, Störk S, Niemann M, et al. Low-gradient aortic valve stenosis myocardial fibrosis and its influence on function and outcome. J Am Coll Cardiol 2011; 58:402.
  28. Barone-Rochette G, Piérard S, De Meester de Ravenstein C, et al. Prognostic significance of LGE by CMR in aortic stenosis patients undergoing valve replacement. J Am Coll Cardiol 2014; 64:144.
  29. Le Ven F, Tizón-Marcos H, Fuchs C, et al. Valve tissue characterization by magnetic resonance imaging in calcific aortic valve disease. Can J Cardiol 2014; 30:1676.
  30. Shavelle DM, Budoff MJ, Buljubasic N, et al. Usefulness of aortic valve calcium scores by electron beam computed tomography as a marker for aortic stenosis. Am J Cardiol 2003; 92:349.
  31. Messika-Zeitoun D, Aubry MC, Detaint D, et al. Evaluation and clinical implications of aortic valve calcification measured by electron-beam computed tomography. Circulation 2004; 110:356.
  32. Ropers D, Ropers U, Marwan M, et al. Comparison of dual-source computed tomography for the quantification of the aortic valve area in patients with aortic stenosis versus transthoracic echocardiography and invasive hemodynamic assessment. Am J Cardiol 2009; 104:1561.
  33. Clavel MA, Messika-Zeitoun D, Pibarot P, et al. The complex nature of discordant severe calcified aortic valve disease grading: new insights from combined Doppler echocardiographic and computed tomographic study. J Am Coll Cardiol 2013; 62:2329.
  34. Clavel MA, Pibarot P, Messika-Zeitoun D, et al. Impact of aortic valve calcification, as measured by MDCT, on survival in patients with aortic stenosis: results of an international registry study. J Am Coll Cardiol 2014; 64:1202.
  35. Jenkins WS, Vesey AT, Shah AS, et al. Valvular (18)F-Fluoride and (18)F-Fluorodeoxyglucose Uptake Predict Disease Progression and Clinical Outcome in Patients With Aortic Stenosis. J Am Coll Cardiol 2015; 66:1200.
  36. Dweck MR, Jenkins WS, Vesey AT, et al. 18F-sodium fluoride uptake is a marker of active calcification and disease progression in patients with aortic stenosis. Circ Cardiovasc Imaging 2014; 7:371.
  37. Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr 2009; 22:1.
  38. Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Eur J Echocardiogr 2009; 10:1.
  39. Rallidis L, Naoumova RP, Thompson GR, Nihoyannopoulos P. Extent and severity of atherosclerotic involvement of the aortic valve and root in familial hypercholesterolaemia. Heart 1998; 80:583.
  40. Summers RM, Andrasko-Bourgeois J, Feuerstein IM, et al. Evaluation of the aortic root by MRI: insights from patients with homozygous familial hypercholesterolemia. Circulation 1998; 98:509.
  41. Sorgato A, Faggiano P, Aurigemma GP, et al. Ventricular arrhythmias in adult aortic stenosis: prevalence, mechanisms, and clinical relevance. Chest 1998; 113:482.
  42. Stortecky S, Buellesfeld L, Wenaweser P, et al. Atrial fibrillation and aortic stenosis: impact on clinical outcomes among patients undergoing transcatheter aortic valve implantation. Circ Cardiovasc Interv 2013; 6:77.
  43. Gersony WM, Hayes CJ, Driscoll DJ, et al. Bacterial endocarditis in patients with aortic stenosis, pulmonary stenosis, or ventricular septal defect. Circulation 1993; 87:I121.
  44. Wilson W, Taubert KA, Gewitz M, et al. Prevention of Infective Endocarditis. Guidelines From the American Heart Association. A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007; 115 published online April 19, 2007. www.circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095v1 (Accessed on May 04, 2007).
  45. Hudzik B, Wilczek K, Gasior M. Heyde syndrome: gastrointestinal bleeding and aortic stenosis. CMAJ 2016; 188:135.
  46. Vincentelli A, Susen S, Le Tourneau T, et al. Acquired von Willebrand syndrome in aortic stenosis. N Engl J Med 2003; 349:343.
  47. Pareti FI, Lattuada A, Bressi C, et al. Proteolysis of von Willebrand factor and shear stress-induced platelet aggregation in patients with aortic valve stenosis. Circulation 2000; 102:1290.
  48. Natorska J, Bykowska K, Hlawaty M, et al. Increased thrombin generation and platelet activation are associated with deficiency in high molecular weight multimers of von Willebrand factor in patients with moderate-to-severe aortic stenosis. Heart 2011; 97:2023.
  49. Blackshear JL, Wysokinska EM, Safford RE, et al. Indexes of von Willebrand factor as biomarkers of aortic stenosis severity (from the Biomarkers of Aortic Stenosis Severity [BASS] study). Am J Cardiol 2013; 111:374.
  50. Boon A, Lodder J, Cheriex E, Kessels F. Risk of stroke in a cohort of 815 patients with calcification of the aortic valve with or without stenosis. Stroke 1996; 27:847.
  51. Roberts WC, Ko JM. Frequency by decades of unicuspid, bicuspid, and tricuspid aortic valves in adults having isolated aortic valve replacement for aortic stenosis, with or without associated aortic regurgitation. Circulation 2005; 111:920.
  52. Otto CM, Burwash IG, Legget ME, et al. Prospective study of asymptomatic valvular aortic stenosis. Clinical, echocardiographic, and exercise predictors of outcome. Circulation 1997; 95:2262.
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