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Normal

Severe Aortic Stenosis


Progression of aortic stenosis
About Aortic Stenosis
Symptoms. Progression. Diagnosing.
Aortic stenosis is a narrowing of the aortic valve opening that restricts normal blood flow to the entire body. It is
estimated to be prevalent in up to 7% of the population over the age of 65. It is a common public health problem
affecting millions of people in the United States. It is also more likely to affect men than women. 80% of adults
with symptomatic aortic stenosis are male.
Aortic stenosis is life threatening and progresses rapidly.
*Otto CM. Timing of aortic valve surgery. Heart. 2000;84:211-21.
Aortic stenosis is a slow, progressive disorder that starts with aortic sclerosis and progresses to aortic stenosis
where there is severe calcification of the leaflets.

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Images courtesy of Renu Virmani MD at the CVPath Institute
Causes of Aortic Stenosis

Major Risk Factors for Aortic Valve Disease
Factors associated with an increased risk of aortic valve disease include the following:
- Increasing age
- Hypertension
- Smoking
- Elevated lipoprotein A
- Elevated LDL cholesterol

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Common Symptoms of Aortic Stenosis
Signs of Aortic Stenosis
- Angina
- Fatigue
- Shortness of breath
- Difficulty when exercising
- Lightheadedness, dizziness, and fainting
- Swollen ankles and feet
- Rapid or irregular heartbeat
- Palpitations - an uncomfortable awareness
of the heart beating rapidly or irregularly
However, heart valve disease may occur with no outward symptoms.

Quality of life is significantly impacted in patients with symptomatic
aortic stenosis
Patients with severe aortic stenosis often develop debilitating symptoms
that can restrict normal day-to-day activities, such as walking short
distances or climbing stairs. These patients can often benefit from surgery
to replace their ailing valve, but only approximately two-thirds of them
undergo the procedure each year.
Valve replacement is the standard of care. Patients today who develop
severe aortic valve stenosis have multiple treatment options
(/hcp/treatment-options).

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Diagnosing Aortic Stenosis
Preliminary Diagnosis of Aortic Stenosis
Detection and estimation of disease severity can often be achieved by auscultation.
Look for:
-Audible systolic heart murmur
-Longer duration with later peak is consistent with more severe stenosis
-Loudness of the murmur does not necessarily correlate with the severity of stenosis
-Soft or absent second heart sound
-Delayed carotid upstroke
Multiple modalities may be used to diagnose severe aortic stenosis
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Grading Severity of Aortic Stenosis


When aortic valve stenosis becomes severe and symptomatic, per ACC/AHA guidelines
(http://circ.ahajournals.org/content/118/8/887), the native valve should be replaced. Left untreated,
aortic valve stenosis may lead to sudden death.

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Aortic Stenosis: Survival After Onset
Patients may live with aortic stenosis for many years during a latent asymptomatic period that precedes the point
that symptoms of the disease develop. However, after patients begin experiencing symptoms, prompt treatment
becomes necessary.
Patient survival after onset and latent period
Once symptoms appear, untreated patients have a poor prognosis. Without treatment, symptomatic aortic
stenosis will eventually lead to death.

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Standard Therapies Are Inadequate for Severe Aortic Stenosis
Cohort B - The PARTNER Trial

- In inoperable patients with severe aortic stenosis who did not receive a valve replacement, 50% died
within one year.
- Despite the frequent utilization of BAV, standard therapy did not do much to alter the dismal course of
disease for inoperable patients with severe aortic stenosis.
Aortic Stenosis: Under-treatment
The only effective treatment for severe aortic stenosis is aortic valve replacement.
If a patient is showing symptoms, treatment is crucial. There are no medications to reverse or slow the progression
of aortic stenosis.
Aortic Valve replacement is the only effective treatment considered a Class I recommendation by the American
College of Cardiology and the American Heart Association. Patients today who develop severe aortic stenosis
have multiple treatment options (/hcp/treatment-options#sthash.EuR7AkT0.dpbs).

A Serious Unmet Need
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Another Treatment Option Now Available
Due to the dismal nature of the disease, diagnosis (/hcp/about-aortic-stenosis#2) and treatment are crucial. Patients
today with severe aortic valve stenosis have multiple treatment options (/hcp/treatment-
options#sthash.EuR7AkT0.dpbs). For high-risk patients and those who are not suitable for surgical aortic valve
replacement, another option is now available - transcatheter aortic valve replacement (TAVR). TAVR is a less
invasive procedure that does not require open heart surgery and results in lengthening patient's lives.
References:
1. Otto CM. Timing of aortic valve surgery. Heart. 2000;84:211-21.
2. Stewart BF, Siscovick D, Lind BK, et al. Clinical factors associated with calcific aortic valve disease. Cardiovascular Health Study. J Am Coll Cardiol. 1997;29:630-634.
3. Bach DS. Prevalence and Characteristics of Unoperated Patients with Severe Aortic Stenosis. J Heart Valve Dis. 2011;20:284-291.
4. Lester SJ, Heilbron B, Dodek A, Gin K, Jue J. The Natural History And Rate Of Progression Of Aortic Stenosis. CHEST. 1998;113(4):1109-1114.
5. Nkomo VY, Gardin JM, Skelton TN et al. Burden of valvular heart diseases: a population-based study. Lancet 2006; 368:1005-11.
6. ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Revise the 1998
Guidelines for the Management of Patients With Valvular Heart Disease) DOI: 10.1161/CIRCULATIONAHA.108.190748. Circulation published online Sep 26, 2008.
7. National Institutes of Health. National Cancer Institute. Surveillance Epidemiology and End Results. Cancer Stat Fact Sheets. http://seer.cancer.gov/statfacts/. Accessed November 16, 2010.
8. Bouma BJ, Van Den Brink RB, Van Der Meulen JH, et al. To operate or not on elderly patients with aortic stenosis: the decision and its consequences. Heart. 1999;82:143-148.
9. Pellikka PA, Sarano ME, Nishimura RA, et al. Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up. Circulation. 2005;111:3290-
3295.
10. Charlson E, Legedza AT, Hamel MB. Decision-making and outcomes in severe symptomatic aortic stenosis. J Heart Valve Dis. 2006;15:312-321.
11. Varadarajan P, Kapoor N, Banscal RC, Pai RG. Clinical profile and natural history of 453 nonsurgically managed patients with severe aortic stenosis. Ann Thorac Surg. 2006;82:2111-2115.
12. Jan F, Andreev M, Mori N, Janosik B, Sagar K. Unoperated patients with severe symptomatic aortic stenosis. Circulation. 2009;120;S753.
13. Bach DS, Siao D, Girard SE, et al. Evaluation of patients with severe symptomatic aortic stenosis who do not undergo aortic valve replacement: the potential role of subjectively overestimated
operative risk. Circ Cardiovasc Qual Outcomes. 2009;2:533-539.
14. Freed BH, Sugeng L, Furlong K, et al. Reasons for nonadherence to guidelines for aortic valve replacement in patients with severe aortic stenosis and potential solutions. Am J Cardiol.
2010;105:1339-1342.
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