Aortic Stenosis: Diagnosis and Treatment

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 afterload 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.