From the Guidelines
The classic triad of symptoms in aortic stenosis consists of angina, syncope, and heart failure, which are late manifestations of the disease and indicate a poor prognosis if left untreated. These symptoms occur due to the severe obstruction of the aortic valve, leading to compromised coronary perfusion, cerebral hypoperfusion, and left ventricular failure 1.
Key Points
- Angina occurs because the hypertrophied left ventricle requires more oxygen while coronary perfusion is compromised due to increased ventricular pressure and decreased diastolic time.
- Syncope typically happens during exertion when peripheral vasodilation occurs but cardiac output cannot increase appropriately due to the fixed obstruction at the aortic valve, leading to cerebral hypoperfusion.
- Heart failure symptoms develop as the left ventricle eventually fails to compensate for the increased afterload, resulting in pulmonary congestion, dyspnea, and fatigue.
Disease Severity and Treatment
The presence of these symptoms indicates severe disease, and prompt evaluation for valve replacement is necessary as mortality increases significantly 1. Severe aortic stenosis is defined as an aortic velocity ≥4.0 m per second or mean pressure gradient ≥40 mm Hg, and the only effective treatment is surgical or transcatheter aortic valve replacement (AVR), resulting in improved survival rates, reduced symptoms, and improved exercise capacity 1.
Clinical Implications
In patients with severe, symptomatic, and calcific aortic stenosis, AVR is indicated in virtually all symptomatic patients and should be performed promptly after onset of symptoms, unless there are serious comorbid conditions that limit life expectancy or quality of life 1.
From the Research
Triad of Symptoms in Aortic Stenosis
The triad of symptoms in aortic stenosis includes:
- Angina
- Syncope
- Heart failure
Characteristics of Each Symptom
- Angina: associated with the presence of coronary stenosis 2, and hypertension 2
- Syncope: associated with a smaller aortic valve area, smaller cardiac cavities, and lower stroke volumes 3, and severity of aortic stenosis 4, 2
- Heart failure: associated with a higher e' ratio and peak aortic valve velocity 2
Clinical Significance of Symptoms
- The presence of any of these symptoms is an indication for aortic valve replacement in patients with significant aortic stenosis 5, 6, 4
- Syncope is associated with a poor prognosis after surgical aortic valve replacement 3
- The development of dyspnea, angina, or syncope is influenced by different factors in aortic stenosis, including severity of aortic stenosis, diastolic dysfunction, and presence of coronary stenosis 2