Aortic Stenosis Features

Expansion

SAD, the classic triad of symptoms:

• S - Syncope, typically exertional
• A - Angina, even with normal coronary arteries
• D - Dyspnoea, from heart failure

“Angina 5, syncope 3, failure 2” gives the untreated survival in years once each symptom appears, which is why symptom onset is the trigger for valve replacement.

Signs

• Slow rising, low volume pulse (pulsus tardus et parvus)
• Narrow pulse pressure
• Heaving, non-displaced apex from pressure overload
• Ejection systolic murmur, loudest in the aortic area, radiating to the carotids
• Soft or absent A2, and a reversed split S2 in severe disease
• S4 from a stiff ventricle

Severity markers: soft or absent A2, reversed splitting, a late peaking murmur, S4, left ventricular failure, and a gradient over 40 mmHg or valve area under 1 cm2 on echocardiography.

Causes by age: bicuspid valve under 65, calcific degeneration over 65, and rheumatic disease.

Distinguish from hypertrophic cardiomyopathy: that has a jerky pulse and a murmur that gets louder with Valsalva, whereas aortic stenosis gets quieter.