Specificities of Aortic Stenosis in Women - From Diagnosis to Management

Aortic stenosis (AS) is the most common valvular heart disease worldwide, with pathophysiology, clinical presentation, and management differing widely according to sex. Women demonstrate predominantly fibrotic valve modifications and less calcifications for given hemodynamic severity, with left ventricular concentric hypertrophy and smaller cavity size leading to a higher prevalence of paradoxical low-flow, low-gradient AS. These sex differences are modulated by hormonal changes, inflammatory and metabolic pathways, as well as genetic and epigenetic regulators. Atypical symptoms and hemodynamic specificities on echocardiography all combine to create diagnostic challenges that contribute to delayed recognition and intervention. Multimodality imaging, particularly the use of sex-specific calcium scoring cutoffs and CMR-derived fibrosis markers, enhances diagnostic precision. While special considerations such as small valvular annulus and peripheral arteries, have to be taken into consideration, both approaches are safe and beneficial in women. The current manuscript reviews sex specificities of AS, in terms of pathophysiology, diagnosis and management.