What is the diagnosis and treatment approach for an older adult patient with symptoms of chest pain, shortness of breath, or syncope suspected of having aortic stenosis?

Diagnosis of Aortic Stenosis

Transthoracic echocardiography is the definitive first-line diagnostic test for aortic stenosis and should be performed immediately in any older adult presenting with the classic triad of chest pain, dyspnea, or syncope, as these symptoms signal severe disease with a mortality of 50% at 2 years if untreated. 1, 2

Clinical Presentation and Physical Examination

The classic symptom triad indicates advanced disease and demands urgent evaluation 2:

• Dyspnea on exertion (most common initial symptom) - signals heart failure
• Angina pectoris - results from reduced coronary reserve and myocardial ischemia despite normal coronary arteries
• Syncope (especially exertional) - reflects inability to increase cardiac output during peripheral vasodilation

Critical Physical Examination Findings

Auscultation provides powerful diagnostic clues 1, 3:

• Late-peaking, crescendo-decrescendo systolic murmur at the right upper sternal border radiating to the carotids indicates severe stenosis 1
• Soft or absent A2 component of S2 is specific (though not sensitive) for severe aortic stenosis - valve calcification prevents normal forceful leaflet closure 1
• Single S2 (absent A2) strongly suggests severe disease 1, 3
• Normally split S2 reliably excludes severe aortic stenosis - this is a critical negative finding 1

Carotid pulse examination 1:

• Delayed, dampened upstroke (pulsus parvus et tardus) indicates severe stenosis

Important pitfall: If physical examination strongly suggests severe aortic stenosis but echocardiography shows only mild stenosis, the echocardiogram has likely underestimated disease severity and requires repeat assessment 1

Diagnostic Testing Algorithm

First-Line: Transthoracic Echocardiography

Echocardiography is the gold standard for diagnosis and severity grading 1, 2:

• Measures mean gradient and aortic valve area
• Assesses left ventricular wall thickness, size, and function
• Evaluates for aortic regurgitation

Severity classification 2:

• Mild: Mean gradient <25 mmHg, valve area >1.5 cm²
• Moderate: Mean gradient 25-40 mmHg, valve area 1.0-1.5 cm²
• Severe: Mean gradient >40 mmHg, valve area <1.0 cm²

Adjunctive Testing

Chest X-ray has limited diagnostic value 4:

• May show aortic contour abnormalities as incidental finding
• Normal aortic silhouette does NOT rule out aortic stenosis
• Useful only to exclude other causes of symptoms

Exercise testing 1, 2:

• May be considered (Class IIb) in asymptomatic patients to elicit exercise-induced symptoms or abnormal blood pressure responses
• Contraindicated (Class III) in symptomatic patients with known aortic stenosis
• Can reveal symptoms not apparent at rest

Follow-Up Surveillance for Asymptomatic Patients

Echocardiography intervals based on severity 1:

• Severe aortic stenosis: Yearly
• Moderate aortic stenosis: Every 1-2 years
• Mild aortic stenosis: Every 3-5 years

Re-evaluation is mandatory when symptoms or signs change 1

Prognostic Implications

Asymptomatic patients have survival comparable to age-matched controls 2

Once symptoms develop, prognosis is dire without intervention 2:

• Mean survival: 5 years after angina onset
• Mean survival: 3 years after syncope onset
• Mean survival: 2 years after heart failure onset
• 25% mortality at 1 year, 50% mortality at 2 years

The appearance of symptoms marks a decisive turning point requiring urgent intervention 2

Activity Restrictions

Physical activity restriction is recommended for patients with moderate to severe aortic stenosis 2