Q&A: Clinical Conditions Associated With Aortic Stenosis

Aortic valve stenosis (AS) is the most common cause of left ventricular outflow obstruction in children and adults; less common causes are subvalvular or supravalvular disease. Surgical aortic valve replacement (AVR) and transcatheter aortic valve implantation (TAVI) are the only effective treatments for severe aortic stenosis. Recommendations for surgical valve replacement for AS are based upon comparisons of the natural history of patients with AS to outcomes after surgical AVR.

This article is for Medical Students & Professionals

This is a Question & Answer revision article designed for medical students and professionals preparing for the PLAB, MRCP or USMLE examinations. They are based on actual questions from these examinations. You may find the Cardiovascular Disease article more useful, or one of our many articles on Diseases & Conditions, Medical Syndromes, Health & Wellness or Home Remedies.

In this article:
Symptoms of aortic stenosis
MCQ exam: clinical scenario
MCQ exam: answer
MCQ exam: explanation

Symptoms of aortic stenosis

The classic clinical manifestations of aortic stenosis (AS) are heart failure (HF), syncope, and angina. However, these "classic" manifestations reflect end-stage disease. Now, with earlier diagnosis by echocardiography and prospective follow-up of patients, the following are the most common presenting symptoms:

• Dyspnea on exertion or decreased exercise tolerance
• Exertional dizziness (presyncope) or syncope
• Exertional angina

These three "early symptoms" are nonspecific. Care must be taken in attributing these symptoms to AS since most patients with these symptoms do not have AS. The patient with AS typically is asymptomatic for a prolonged period despite the obstruction and increased pressure load on the left ventricle (LV).

MCQ exam: clinical scenario

A 56 year old male has a history of aortic stenosis.

Which of the following is associated with aortic stenosis?

a). Atrial fibrillation
b). Systolic ejection murmur
c). Increased pulse pressure
d). Diastolic murmur
e). Right heart failure

MCQ exam: answer

The correct answer is B.

MCQ exam: explanation

With aortic stenosis there is a systolic ejection murmur that is heard loudest at the second right intercostal space (the aortic area). A systolic ejection murmur is also seen with pulmonic stenosis, however this is best heard in the second left intercostal space.

Atrial fibrillation is common in mitral stenosis. It is also seen in mitral regurgitation, however, less commonly than with mitral stenosis. Aortic stenosis typically is not associated with atrial fibrillation.

The pulse pressure is the difference between systolic and diastolic pressure. An increased pulse pressure is seen with aortic regurgitation. It manifests itself with various signs: Quincke's sign, Duroziez's sign and a 'water hammer pulse'.

Diastolic murmur is heard with several different valvular conditions, including aortic regurgitation. A diastolic murmur is not heard with aortic stenosis. The murmur of aortic stenosis is heard during systole.

The symptoms of aortic stenosis include left ventricular failure (exertional syncope and angina are also symptoms). Ventricular arrhythmias may cause sudden death. A slow-rising pulse with narrow pulse pressure, thrusting apex, and harsh systolic ejection murmur (palpated as a thrill) at the aortic area radiating to the neck, which may or may not be preceded by an ejection click, is elucidated. A2 may be absent or paradoxically split.

Reference(s)
1). UpToDate: Clinical manifestations and diagnosis of aortic stenosis in adults. Available online: https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-aortic-stenosis-in-adults
2). UpToDate: Indications for valve replacement in aortic stenosis in adults. Available online: https://www.uptodate.com/contents/indications-for-valve-replacement-in-aortic-stenosis-in-adults