What are the key components to include when taking a history in a patient with aortic stenosis?

History Taking in Aortic Stenosis

When evaluating a patient with aortic stenosis, you must systematically assess for the classic triad of symptoms (dyspnea, angina, syncope), exercise tolerance, and risk factors for sudden cardiac death, as the presence of symptoms dramatically changes prognosis from a benign course to a 2-3 year survival without intervention. 1, 2

Cardinal Symptoms to Elicit

The Classic Triad

• Dyspnea on exertion or at rest - most common symptom and most strongly associated with severe AS 1, 3
• Angina pectoris - occurs even without coronary disease due to increased myocardial oxygen demand from left ventricular hypertrophy 1
• Syncope or presyncope - particularly exertional syncope, which indicates critically severe stenosis 1

Critical point: Once any of these symptoms develop, mortality increases dramatically with 8-34% sudden cardiac death risk in symptomatic patients versus only 3-5% in asymptomatic patients 1. Average survival without valve replacement drops to 2-3 years after symptom onset 2.

Exercise Tolerance Assessment

• Quantify functional capacity - ask about ability to perform specific activities (climbing stairs, walking distances, household tasks) 1
• Document any exercise-induced symptoms - excessive dyspnea early in exercise, dizziness, chest discomfort, or near-syncope 1
• Assess for subtle activity limitation - elderly or sedentary patients may unconsciously reduce activity to avoid symptoms 1

Pitfall to avoid: Patients, especially elderly individuals with multiple comorbidities, often attribute symptoms to aging or other conditions rather than AS 1, 3. Probe specifically about changes in exercise capacity over time.

Medical History Components

Cardiovascular Risk Factors and Comorbidities

• Hypertension - present in 53-57% of AS patients 3
• Coronary artery disease - present in approximately 46% of AS patients 3, 2
• Atrial fibrillation - present in 30-35% of AS patients 3
• Renal insufficiency - independent predictor of mortality in unoperated AS 4

Medication History

• Beta-blocker use - associated with improved survival in asymptomatic severe AS (RR 0.52) 4
• Statin use - associated with improved survival in asymptomatic severe AS (RR 0.52) 4
• Current cardiac medications - document all antihypertensives, anticoagulants, and antiplatelet agents 2

Family History

Genetic and Familial Conditions

• Family history of aortic valve disease - including bicuspid aortic valve, which is a common congenital cause 1
• Connective tissue disorders - Marfan syndrome, Loeys-Dietz syndrome, vascular Ehlers-Danlos syndrome, Turner syndrome 1
• Family history of sudden cardiac death - particularly in young relatives 1
• Family history of thoracic aortic aneurysm or dissection - strong familial component to aortic disease 1

Etiology and Risk Assessment

Determine Underlying Cause

• Age at diagnosis - calcific/degenerative AS typically occurs in elderly (>65 years) 1, 2
• History of rheumatic fever - particularly in younger patients or those from endemic areas 1
• Congenital abnormalities - bicuspid aortic valve presents earlier, typically in 4th-6th decade 1

Assess Disease Progression

• Duration of known AS - average increase in mean gradient is 7 mmHg per year 1
• Previous echocardiographic data - rapid progression (aortic jet velocity increase ≥0.3 m/sec per year) predicts poor outcomes 5
• Timing of symptom onset - recent symptom development indicates need for urgent intervention 1, 2

Surgical and Procedural History

• Previous cardiac surgery or interventions - including coronary bypass, valve procedures, or catheter-based interventions 1
• Recent aortic manipulation - predisposes to complications including dissection 1

Functional Status and Quality of Life

• Baseline activity level - sedentary patients may not manifest symptoms until disease is very advanced 1
• Occupational demands - physical labor requirements may unmask symptoms earlier 1
• Impact on daily activities - quantify limitations in self-care, household tasks, and social activities 1

Key clinical decision point: The distinction between symptomatic and asymptomatic status is critical, as symptomatic patients require prompt valve replacement while asymptomatic patients can be safely monitored with watchful waiting 1, 5, 2. When symptom status is uncertain in sedentary or elderly patients, exercise stress testing should be performed to clarify 1.