Aortic Stenosis: Diagnosis and Treatment

 


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Am Fam Physician. 2016 Mar 1;93(5):371-378.

  Patient information: See related handout on aortic stenosis, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Aortic stenosis affects 3% of persons older than 65 years. Although survival in asymptomatic patients is comparable to that in age- and sex-matched control patients, it decreases rapidly after symptoms appear. During the asymptomatic latent period, left ventricular hypertrophy and atrial augmentation of preload compensate for the increase in after-load caused by aortic stenosis. As the disease worsens, these compensatory mechanisms become inadequate, leading to symptoms of heart failure, angina, or syncope. Aortic valve replacement is recommended for most symptomatic patients with evidence of significant aortic stenosis on echocardiography. Watchful waiting is recommended for most asymptomatic patients. However, select patients may also benefit from aortic valve replacement before the onset of symptoms. Surgical valve replacement is the standard of care for patients at low to moderate surgical risk. Transcatheter aortic valve replacement may be considered in patients at high or prohibitive surgical risk. Patients should be educated about the importance of promptly reporting symptoms to their physicians. In asymptomatic patients, serial Doppler echocardiography is recommended every six to 12 months for severe aortic stenosis, every one to two years for moderate disease, and every three to five years for mild disease. Cardiology referral is recommended for all patients with symptomatic moderate and severe aortic stenosis, those with severe aortic stenosis without apparent symptoms, and those with left ventricular systolic dysfunction. Medical management of concurrent hypertension, atrial fibrillation, and coronary artery disease will lead to optimal outcomes.

Aortic valve stenosis affects 3% of persons older than 65 years and is the most significant cardiac valve disease in developed countries.1 Its pathology includes processes similar to those in atherosclerosis, including lipid accumulation, inflammation, and calcification.2 The development of significant aortic stenosis tends to occur earlier in persons with congenital bicuspid aortic valves and in those with disorders of calcium metabolism, such as in renal failure.3 Although the survival rate in asymptomatic patients is comparable to that in age- and sex-matched control patients, it decreases rapidly after symptoms appear.

WHAT IS NEW ON THIS TOPIC: AORTIC STENOSIS

In patients with aortic stenosis, the 10-year cardiovascular risk should be determined and the benefits and risks of statin therapy and aspirin prophylaxis should be discussed based on current guidelines.

Transcatheter aortic valve replacement is recommended for patients who have an indication for aortic valve replacement but are at prohibitive surgical risk. Transcatheter valve replacement is also a reasonable alternative to surgical replacement in high-risk patients.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Transthoracic echocardiography is indicated when there is a loud unexplained systolic murmur, a single second heart sound, a history of a bicuspid aortic valve, or symptoms that might be caused by aortic stenosis.

C

1820

Aortic valve replacement is the only treatment that improves mortality in patients with symptomatic severe aortic stenosis.

B

2832

Watchful waiting is recommended for most patients with asymptomatic aortic stenosis.

B

20, 25, 34, 36

In asymptomatic patients, serial Doppler echocardiography is recommended every six to 12 months in patients with severe aortic stenosis, every one to two years in those with moderate disease, and every three to five years in those with mild disease.

C

20

Antimicrobial prophylaxis for bacterial endocarditis is not recommended for patients with aortic stenosis unless they have undergone aortic valve replacement or have a history of endocarditis.

C

49


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Transthoracic echocardiography is indicated when there is a loud unexplained systolic murmur, a single second heart sound, a history of a bicuspid aortic valve, or symptoms that might be caused by aortic stenosis.

C

1820

Aortic valve replacement is the only treatment that improves mortality in patients with symptomatic severe aortic stenosis.

B

2832

Watchful waiting is recommended for most patients with asymptomatic aortic stenosis.

B

20, 25, 34, 36

In asymptomatic patients, serial Doppler echocardiography is recommended every six to 12 months in patients with severe aortic stenosis, every one to two years in those with moderate disease, and every three to five years in those with mild disease.

C

20

Antimicrobial prophylaxis for bacterial endocarditis is not recommended for patients

The Authors

show all author info

BRIAN H. GRIMARD, MD, is an instructor at the Mayo Medical School in Jacksonville, Fla....

ROBERT E. SAFFORD, MD, PhD, is a professor of medicine at the Mayo Medical School in Jacksonville.

ELIZABETH L. BURNS, MD, is an instructor at the Mayo Medical School in Jacksonville.

Address correspondence to Brian H. Grimard, MD, Mayo Clinic, 4500 San Pablo Rd. S., Jacksonville, FL 32224 (e-mail: grimard.brian@mayo.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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show all references

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