Aortic stenosis for PACES

The pulse in aortic stenosis is slow rising and of a low-volume.  
The apex beat is usually undisplaced and heaving. 
There may be an apical thrill. 
The murmur is ejection systolic and radiates to the carotids. 
(The second heart sound may be soft or absent)

A mental picture: the elderly Mrs Aortic Stenosis slowly rises from her garden chair holding a half-filled glass (slow rising, low volume pulse). She is heaving with the effort but has not yet moved (heaving, undisplaced apex beat). She notices a pilots seat on the apex of a nearby hill nearby with an ejection button... this gives her a slight thrill (apical thrill) and she murmurs how nice it would be if it ejected her towards her car (ejection systolic murmur radiating to the carotids).

Recap of Part 1 and 2 notes on aortic stenosis here

Possible complications to look out for include LEC: left ventricular failure, endocarditis and conduction problems.

Signs of severe AS include: evidence of LVF, narrow pulse pressure, soft/absent S2, reversed S2, thrill/heave, S4.

Differential diagnoses include VSD, aortic sclerosis, aortic flow murmur, HOCM, pulmonary stenosis, mitral regurgitation.

How would you investigate aortic stenosis?
  • basic investigations: ECG, looking for LVH, LAD and maybe complete heart block if calcification involves conduction tissue, and CXR, looking for potentially a calcified valve
  • echocardiogram: pay particular attention to the valve area (<1cm2 is severe, <0.7cm2 is critical), the gradient (>40mmHg peak drop is severe) and the LVEF (<50% is an indication for surgery)

How would you manage aortic stenosis?
  • if symptomatic, ie angina, dyspnoea or syncope, surgery is indicated - 5 yr survival without surgery is just 15-50%.  Aortic valve replacement carries a mortality of around 3-5% for those under 70 without LVF; with LVF mortality increases to up to 25%.  If the patient is not fit enough for surgery, TAVI (transcatheter aortic valve insertion) could be considered.
  • if patient is asymptomatic, surgery is generally not indicated, although it can be in certain cases, such as when LVEF is <50%.  Asymptomatic patients should however be followed up 6 monthly, if severe AS, or yearly if mild to moderate AS.
  • Atherosclerotic risk factors should be addressed.  
  • Antibiotic prophylaxis against infective endocarditis is no longer recommended for AS.
  • In severe AS, avoid drugs that reduce the afterload (and therefore exacerbate the pressure drop across the valve) such as amlodipine (calcium-channel blocker), ramipril (ACE-i) or GTN.


Do you know of any conditions associated with aortic stenosis?
  • coarctation of the aorta
  • GI bleeds due to angiodysplasia - one theory for this is Heyde Syndrome
  • microangiopathic haemolytic anaemia
  • Williams syndrome - elfin facial appearence, low IQ, hypercalcaemia and supravalvular aortic stenosis.

Examples of the aortic stenotic murmur:

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Secret collector of interesting anonymised ECGs. Fan of the Bath Photomarathon. Lover of cream teas. [Sarah Hudson] (Your Picture)