From the Guidelines
Severe aortic stenosis (AS) is characterized by symptoms such as exertional dyspnea, decreased exercise tolerance, heart failure symptoms, exertional angina, exertional syncope, or presyncope, and is defined by valve hemodynamics including AV Vmax ≥4 m/s, mean DP ≥40 mm Hg, or AVA typically ≤1.0 cm². These symptoms and hemodynamic thresholds are critical for identifying patients with severe AS, as they are associated with a high risk of death if aortic valve replacement (AVR) is not performed, with mortality rates as high as 50% at 1 year 1. The diagnosis of severe AS can be confirmed using echocardiography, which assesses the degree of valve calcification, left ventricular (LV) function and wall thickness, and detects the presence of other associated valve disease or aortic pathology 1. Some patients with severe AS may present with low-flow, low-gradient severe AS with preserved left ventricular ejection fraction (LVEF), characterized by a severely calcified aortic valve, an aortic velocity <4.0 m/s, and a valve area ≤1.0 cm² when stroke volume index is <35 mL/m² 1. Key signs of severe AS include:
- Exertional dyspnea or decreased exercise tolerance
- Heart failure symptoms
- Exertional angina
- Exertional syncope or presyncope
- A harsh, crescendo-decrescendo systolic murmur heard best at the right upper sternal border
- A delayed and diminished carotid pulse (pulsus parvus et tardus)
- A sustained apical impulse
- Possibly an S4 heart sound Prompt recognition of these signs is crucial, as severe AS carries a high mortality risk without intervention, and treatment with AVR can significantly improve survival, symptoms, and LV systolic function 1.
From the Research
Signs of Severe Aortic Stenosis (AS)
- Symptoms of severe AS include:
- Severe AS can also present with asymptomatic patients, but symptomatic patients are more common, with 80.3% of patients experiencing symptoms 2
- Patients with severe AS often have advanced disease stage, with 62.1% having left ventricular hypertrophy and 27.3% having an ejection fraction (EF) <50% 2
Disease Severity and Treatment
- Severe AS is typically defined by echocardiography criteria, including aortic valve area (AVA) <1 cm2, indexed AVA <0.6 cm2/m2, maximum jet-velocity (Vmax) >4 m/s and/or mean transvalvular gradient >40 mm Hg 2
- Treatment options for severe AS include transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) 4, 3, 5, 6
- The choice of intervention should be made after evaluating an individual case based on its clinical features and the user's experience with TAVR 3