Classic Clinical Manifestations of Aortic Stenosis
The three classic clinical manifestations of aortic stenosis are dyspnea on exertion, syncope, and angina. 1
The Classic Triad
The cardinal symptoms of aortic stenosis form a well-established triad that signals severe disease:
- Dyspnea on exertion develops as the left ventricle fails to compensate for the increased afterload, leading to heart failure symptoms 1, 2
- Angina pectoris occurs due to increased oxygen demand from left ventricular hypertrophy combined with reduced coronary reserve, even in the absence of coronary artery disease 1, 2
- Syncope or near-syncope, particularly with exertion, results from the inability to increase cardiac output adequately during physical activity 1, 2
Underlying Mechanisms
Each symptom reflects distinct pathophysiologic processes, though all relate to severe stenosis:
- Dyspnea is primarily associated with AS severity (higher peak aortic valve velocity) and diastolic dysfunction (higher E/e' ratio), indicating the development of heart failure 2
- Syncope correlates most directly with the severity of the stenosis itself, representing inadequate cerebral perfusion during increased demand 2
- Angina is influenced by both AS severity and the presence of concurrent coronary artery disease—in one study, 69% of AS patients with angina had significant coronary stenosis (>50% diameter stenosis) on angiography 2
Critical Clinical Context
This classic triad typically appears late in the disease course when left ventricular dysfunction has already developed. 1 The prognostic significance is dramatic:
- Once symptoms develop, mortality rates reach 25% at 1 year and 50% at 2 years if left untreated 1
- Average survival after symptom onset is approximately 2 years for heart failure, 3 years after syncope, and 5 years after angina without valve replacement 1
- In contrast, asymptomatic patients with severe AS have relatively good prognosis with low risk of sudden cardiac death 1
Important Caveats
The presence of hypertension can contribute to angina symptoms independent of AS severity, and coronary stenosis is significantly associated with angina in AS patients 2. Therefore, angina in an AS patient warrants evaluation for concurrent coronary disease rather than assuming it results solely from the valvular pathology.
The correct answer is: Dyspnea on exertion, syncope, and angina. 1, 2, 3, 4, 5, 6