From the Guidelines
Aortic stenosis murmur is a significant clinical finding that requires prompt evaluation and management to prevent morbidity and mortality, and the diagnosis of severe aortic stenosis must be based on an integrated approach including transvalvular velocity/gradient, valve area, valve morphology, flow rate, LV morphology and function, blood pressure and symptoms, as recommended by the European Association of Cardiovascular Imaging and the American Society of Echocardiography 1. The murmur is typically a harsh, crescendo-decrescendo systolic murmur best heard at the right upper sternal border (second intercostal space) with radiation to the carotid arteries. It results from turbulent blood flow through a narrowed aortic valve during systole. The murmur typically increases in intensity with maneuvers that decrease venous return, such as standing or the Valsalva maneuver, and decreases with squatting or handgrip exercises. Associated findings may include a delayed and diminished carotid pulse (pulsus parvus et tardus), a sustained apical impulse, and an absent or diminished aortic component of the second heart sound. The classic triad of symptoms in severe aortic stenosis includes angina, syncope, and heart failure, though patients may remain asymptomatic for years despite significant stenosis. Diagnosis is confirmed with echocardiography, which can assess valve morphology and calculate the valve area and pressure gradient, as outlined in the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease 1. Management depends on severity and symptoms, with valve replacement (surgical or transcatheter) being the definitive treatment for symptomatic severe aortic stenosis. Regular follow-up with serial echocardiograms is essential for asymptomatic patients to monitor disease progression, with the frequency of follow-up depending on the severity of the stenosis, as recommended by the ACC/AHA guidelines 1. Some key points to consider in the diagnosis and management of aortic stenosis include:
- The importance of an integrated approach to diagnosis, including clinical evaluation, echocardiography, and other imaging modalities 1
- The need for regular follow-up and monitoring of disease progression in asymptomatic patients 1
- The importance of considering the patient's symptoms, valve morphology, and other factors in determining the optimal treatment approach 1
- The role of valve replacement (surgical or transcatheter) in the management of symptomatic severe aortic stenosis 1.
From the Research
Aortic Stenosis Murmur
- Aortic stenosis is a condition where the aortic valve becomes narrowed, obstructing blood flow from the heart to the rest of the body 2.
- Severe symptomatic aortic stenosis can lead to death, with mortality rates of approximately 50% within 2 years of symptom onset if left untreated 2.
- The only effective treatment for symptomatic aortic stenosis is surgical aortic valve replacement or transcatheter aortic valve replacement (TAVR) 2, 3, 4.
Treatment Options
- Surgical aortic valve replacement (SAVR) is a traditional treatment option for aortic stenosis, but it may not be suitable for all patients, especially those with advanced age and multiple comorbidities 2, 3.
- TAVR is a less invasive approach that has emerged as a viable alternative to SAVR, especially for patients who are at high risk for surgical complications 2, 3, 4.
- Transcarotid transcatheter aortic valve replacement (TC-TAVR) is another alternative access option for patients with severe aortic stenosis who are not suitable for transfemoral TAVR 5.
Clinical Outcomes
- Studies have shown that TAVR and SAVR have similar clinical outcomes in terms of mortality and stroke rates, but TAVR may have a lower risk of acute kidney injury and bleeding events 6, 5.
- TC-TAVR has been shown to have improved 30-day clinical outcomes compared to SAVR, with no significant differences in death, stroke, and hospitalization at 1-year follow-up 5.
- The choice of treatment should be individualized based on patient characteristics, anatomical risk factors, and patient preference 6.