Symptoms of Aortic Stenosis
The classic triad of symptoms in aortic stenosis consists of exertional dyspnea, angina pectoris, and syncope—once any of these symptoms appear in the setting of severe aortic stenosis, average survival drops dramatically to 2-3 years without intervention. 1, 2
Cardinal Symptoms
Dyspnea (Most Common)
- Exertional dyspnea is the most frequent presenting symptom and most strongly associated with severe aortic stenosis 2, 3
- Progresses from dyspnea on exertion to dyspnea at rest as disease advances 2
- Reflects heart failure symptoms as compensatory mechanisms (left ventricular hypertrophy and atrial augmentation) become inadequate 4, 5
- Patients may report excessive dyspnea early in exercise, even with minimal activity 1
Angina Pectoris
- Occurs in approximately 50-70% of symptomatic patients, even in the absence of coronary artery disease 2, 3
- Results from increased myocardial oxygen demand due to left ventricular hypertrophy combined with reduced coronary perfusion pressure 2
- May present as typical exertional chest pain or pressure 3
Syncope or Presyncope
- Exertional syncope indicates critically severe stenosis and is particularly ominous 2, 3
- Caused by inability to increase cardiac output during exercise, leading to cerebral hypoperfusion 3
- Dizziness or near-syncope during activity should be taken seriously 1, 2
Functional Capacity Assessment
Quantify specific functional limitations rather than accepting vague complaints: 2
- Ability to climb stairs (number of flights) 2
- Walking distances before symptom onset 2
- Capacity to perform household tasks 2
- Occupational demands and impact on daily activities 2
Critical Clinical Pitfall
The distinction between "asymptomatic" and "symptomatic" is absolutely critical—symptomatic patients require prompt valve replacement, while truly asymptomatic patients can be safely monitored. 2 However, this can be difficult to discern in elderly, sedentary populations with multiple comorbidities 1. When uncertainty exists about symptom status, exercise stress testing is recommended to clarify whether symptoms are truly related to aortic stenosis 1.
An abnormal exercise stress test includes: 1
- Exercise-induced angina
- Excessive dyspnea early in exercise
- Dizziness or syncope
- Limited exercise capacity below age/sex-predicted metabolic equivalents
- Abnormal blood pressure response (hypotension or failure to increase BP with exercise)
- Increase in mean gradient with exercise ≥18 mmHg
Additional Important Symptoms
- Heart failure symptoms (orthopnea, paroxysmal nocturnal dyspnea, peripheral edema) develop as left ventricular function deteriorates 3, 5
- Fatigue and exercise intolerance may be subtle early indicators 5
- Palpitations if concurrent atrial fibrillation develops 4, 5
Prognostic Significance
The asymptomatic latent period can last years with survival comparable to age-matched controls, but once symptoms appear, prognosis becomes dire without intervention. 1, 4, 5 Average survival after symptom onset: 4, 6
- Heart failure symptoms: 2 years
- Syncope: 3 years
- Angina: 5 years
Patients must be educated about the critical importance of promptly reporting any new symptoms to their physicians, as this represents a medical emergency requiring urgent evaluation for valve replacement. 4, 5