Diagnosis and Management of Aortic Stenosis
SUMMARY
Aortic stenosis (AS) is a common valvular lesion. In a pooled analysis, 12% of individuals 75 years of age or older had calcific AS. With the aging of the population, the number of individuals with AS is expected to increase in the coming decades.
- Causes of AS
- Stages of Aortic Stenosis
- Signs and Symptoms of AS
- Diagnosis and Follow-Up
- Exercise testing in patients with AS
- Medical Therapy of AS
- Intervention of AS
- Antiplatelet/Anticoagulant therapy post AVR
Causes of AS
- Calcification of a normal tri-leaflet valve
- Congenital bicuspid valve with superimposed calcification
- Rheumatic valvular disease
Stages of Aortic Stenosis
- Stage A
- At risk of AS: Patients with aortic valve sclerosis with underlying congenital valve abnormalities
- Stage B:
- Progressive AS
- Mild to moderate AS
- Stage C
- Asymptomatic Severe AS
- Stage D
- Symptomatic Severe AS
Signs and Symptoms of AS
- Symptoms
- Dyspnea | Angina | Syncope | Decrease in exercise tolerance | Fatigue | Heart Failure symptoms if late stage
- Signs
- Parvus and Tardus carotid impulse: slow-rising, late-peaking, low-amplitude carotid pulse | Systolic ejection murmur typically late-peaking, best heard at base of heart with radiation to carotids
Note: The louder and later-peaking murmur the more severe the stenosis
Diagnosis and Follow-Up
- TTE
- Indicated in patients with signs and symptoms of AS or Bicuspid Aortic Valve
- Severe AS
- Defined by TTE as an aortic peak velocity of ≥ 4 m/s or mean gradient ≥ 40 mm Hg
- Aortic valve area typically ≤ 1.0 cm2
- Severity of AS in doubt (low-flow, low-gradient AS)
- Cardiac Computer Tomography (CT) can be helpful.
- Thresholds for diagnosis of severe AS in Agaston units are 1300 in women and 2000 in men
- Obtain repeat TTE if a change in exam or symptoms attributable to AS is suspected
- Frequency of TTE in asymptomatic patients with AS
- Mild: Every 3 to 5 years
- Moderate: 1 to 2 years
- Severe (asymptomatic): Every 6 months to 1 year
Exercise Testing in patients with AS
- Asymptomatic with severe AS
- Exercise testing is reasonable to assess to confirm absence of symptoms
- Symptomatic with severe AS
- Exercise testing in contraindicated
Medical Therapy of AS
- Stage A-C patients: Treat hypertension as needed
- Calcific AS: Do not use statin therapy solely for the purpose of preventing hemodynamic progression of AS
Surgical Intervention for AS
- Aortic Valve Replacement (AVR) is indicated for the following
- Symptomatic AS
- Asymptomatic AS with severe AS and LVEF <50%
- Asymptomatic with severe AS if undergoing cardiac surgery for other indications
NOTE: The decision to proceed with TAVR (Transcatheter Aortic Valve Replacement) or SAVR (Surgical Aortic Valve Replacement) is dependent on multiple patient and procedural factors | Additionally, the decision between a bioprosthetic vs mechanical aortic valve should consider patient’s values, preferences, co-morbid conditions, and risks of anticoagulant therapy
Antiplatelet/Anticoagulant Therapy post AVR
- Bioprosthetic SAVR or TAVR
- Daily low-dose aspirin is recommended lifelong in addition to vitamin K antagonist (VKA) anticoagulation with INR goal of 2.5 for first 3 to 6 months
- Mechanical AVR
- Anticoagulation ONLY with VKA is recommended
- DOACs (Direct Oral Anticoagulants) are contraindicated
- INR goals for patients with mechanical valves
- Mechanical AVR with On-X valve: INR goal 1.5 to 2
- Mechanical AVR with no other risk factors: INR goal 2.5
- Mechanical AVR with other risk factors: INR goal 3
Notes: Risk factors include older generation valve, atrial fibrillation, previous thromboembolism, hypercoagulable state, and LV dysfunction
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