Does Aortic Stenosis Cause Chest Pain?
Yes, aortic stenosis definitively causes chest pain (angina) through two primary mechanisms: coronary microvascular dysfunction from elevated left ventricular pressure and left ventricular hypertrophy (most common), and coexisting obstructive coronary artery disease (also common due to shared risk factors). 1, 2
Primary Mechanisms of Chest Pain in Aortic Stenosis
Supply-demand mismatch is the predominant mechanism causing angina in severe aortic stenosis, resulting from markedly elevated left ventricular pressure due to high afterload combined with left ventricular hypertrophy. 1, 2 This occurs even in the absence of epicardial coronary artery disease because the hypertrophied myocardium has increased oxygen demands that cannot be met by the compressed coronary microvasculature. 2
Coexisting obstructive coronary artery disease is the second major cause of chest pain in aortic stenosis patients, as both conditions share common risk factors including age, hypertension, and atherosclerosis. 1, 2 Studies show that coronary artery disease is present in approximately 46% of patients with aortic stenosis. 3
Clinical Presentation
Angina is one of the three classic symptoms of severe aortic stenosis (along with dyspnea and syncope), and its onset significantly shortens life expectancy to approximately 3 years without intervention. 4, 5
However, a critical caveat: symptoms do not reliably predict the severity of aortic stenosis. 6 In a study of 100 adults with suspected aortic stenosis, the prevalence of symptoms and functional class were similar between patients with significant versus nonsignificant stenosis. 6 Angina was related to coronary artery disease presence but not to the severity of aortic stenosis itself. 6
Chest pain is common in both moderate and severe aortic stenosis. 3 In a large cohort study, angina prevalence was similar between moderate and severe aortic stenosis patients, whereas dyspnea was more strongly associated with severe disease. 3
Diagnostic Approach
Transthoracic echocardiography (TTE) is the first-line diagnostic tool (Class I recommendation) to determine aortic stenosis severity, assess left ventricular function, and evaluate for other valvular pathology. 1, 2
When TTE quality is inadequate, transesophageal echocardiography with 3D imaging should be performed. 1
Coronary angiography is essential in the pre-intervention workup to identify concomitant coronary artery disease requiring simultaneous revascularization. 2 The American College of Cardiology recommends preoperative coronary angiography in patients being evaluated for valve replacement, with decisions based on age, symptoms, and coronary risk factors. 2
Critical pitfall: Do not attribute all chest pain to aortic stenosis alone—systematic evaluation for coronary artery disease is mandatory, as both conditions frequently coexist. 2 Approximately 31% of patients without angina still had coronary artery disease in one study, meaning coronary disease cannot be excluded without selective coronary angiography. 6
Management Implications
Aortic valve replacement is indicated for all symptomatic patients with severe aortic stenosis, regardless of whether chest pain is from microvascular dysfunction or coexisting coronary artery disease. 2
The choice between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) depends on surgical risk, with SAVR preferred for low-risk patients and TAVR appropriate for intermediate/high-risk patients. 2
Concomitant significant coronary artery disease requiring coronary artery bypass grafting favors surgical aortic valve replacement over TAVR in appropriate candidates. 2
Risk Stratification
Exercise stress testing is crucial when symptom status is uncertain, with exercise-induced angina representing an abnormal test. 2 An increase in mean gradient with exercise ≥18 mmHg is associated with increased event rates. 2
Maintain hemodynamic stability during any invasive procedures, avoiding vasodilators and ensuring adequate preload, as patients with aortic stenosis are preload-dependent and afterload-sensitive. 2