Aortic valve stenosis

Last updated: August 4, 2023

Summarytoggle arrow icon

Aortic valve stenosis (AS) is a valvular heart disease characterized by narrowing of the aortic valve. As a result, the outflow of blood from the left ventricle into the aorta is obstructed. This leads to chronic and progressive excess load on the left ventricle and potentially left ventricular failure. The patient may remain asymptomatic for long periods of time; for this reason, AS is often detected late when it first becomes symptomatic (dyspnea on exertion, angina pectoris, or syncope). Auscultation reveals a harsh, crescendo-decrescendo murmur in systole that radiates to the carotids, and pulses are delayed with diminished carotid upstrokes. Echocardiography is the noninvasive gold standard for diagnosis. Patients with mild asymptomatic aortic stenosis are treated conservatively with monitoring and medical management of related conditions (e.g., hypertension). Symptomatic patients, or those with severe aortic valve stenosis, require immediate aortic valve replacement (AVR) as definitive treatment. Options for valve replacement include surgical AVR or transcatheter AVR (TAVR) for patients with high operative risk. Patients with severe AS have a high risk of developing acute complications such as heart failure and cardiogenic shock, which are challenging to manage and often require critical care interventions and expedited surgery or TAVR.

Epidemiologytoggle arrow icon

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

The most common etiologies of valvular aortic stenosis include:

Aortic valve sclerosis occurs without aortic stenosis in its early stages, but can progress to aortic stenosis once signs of LVOT obstruction begin to occur. [5]

Pathophysiologytoggle arrow icon


Clinical featurestoggle arrow icon

Aortic stenosis may remain asymptomatic for years, particularly with mild or moderate stenosis. Symptoms usually start to develop when the disease progresses to severe AS, and may present at rest or on exertion.

To remember the three major symptoms of aortic valve stenosis, think: SAD (syncope, angina, dyspnea).


Classificationtoggle arrow icon

American Heart Association (AHA)/American College of Cardiology (ACC) staging system [9][10]

  • Used to monitor disease progression and determine the need for intervention
  • Based on echocardiographic criteria of valve anatomy and hemodynamics
    • Aortic valve area (AVA): the opening area of the aortic valve measured during systole and an important factor in the evaluation of severity of aortic valve stenosis
    • Transaortic velocity: the maximum velocity of blood flow measured across the aortic valve during systole; inversely related to the aortic valve area
    • Mean aortic pressure gradient: the difference in pressure between the left ventricle and the ascending aorta during systole
      • Pressures normally equilibrate relatively rapidly when the valve opens.
      • Valvular stenosis limits the increase in aortic pressure while increasing the LV pressure, leading to a higher gradient.
  • The term critical aortic stenosis is commonly used to describe severe AS and/or decompensated AS, however, there is a lack of consensus on the defining parameters. [11][12]
AHA/ACC staging for aortic valve stenosis [9][10]
Severity Definition AVA Transaortic velocity Mean aortic pressure gradient
Mild-to-moderate aortic stenosis Stage A aortic valve stenosis At risk of AS 3–4 cm2 < 2.0 m/second < 10 mm Hg
Stage B aortic valve stenosis Progressive AS Mild: 1.5–2.9 cm2 2.0– 2.9 m/second 10–19 mm Hg
Moderate: 1.0–1.4 cm2 3.0–3.9 m/second 20–39 mm Hg
Severe aortic stenosis Stage C1 aortic valve stenosis Asymptomatic severe AS (LVEF normal) ≤ 1.0 cm2 ≥ 4.0 m/second ≥ 40 mm Hg
Stage C2 aortic valve stenosis

Asymptomatic severe AS with LV dysfunction (LVEF < 50%)

Stage D aortic valve stenosis Symptomatic severe AS

Diagnosticstoggle arrow icon

Initial evaluation

Echocardiography [9]


Additional evaluation [9]

Low-dose dobutamine stress testing

Exercise stress testing

Exercise stress testing is contraindicated in patients with severe symptomatic AS (stage D).

Cardiac catheterization

Advanced imaging [9][19]

Consider the following noninvasive imaging options in the perioperative assessment of patients with severe AS, along with expert consultation.

  • Cardiac CT
    • Used in select patients to rule out concomitant CAD if pretest probability is low
    • Can quantify valve calcification
    • Useful for specific measurements required prior to TAVR
  • Cardiac MRI
    • Provides precise information on anatomy and hemodynamics
    • Can be helpful in evaluating severity of AS but is not always available

Differential diagnosistoggle arrow icon

Treatmenttoggle arrow icon

AS is a progressive condition that is definitively treated with aortic valve replacement or repair, the urgency of which depends on disease severity (see “Staging aortic valve stenosis”).

Approach [9]

Supportive care

Managing comorbidities [9][10]

Screen and treat all patients for ASCVD risk factors (see “ASCVD prevention”). [9]

Echocardiographic monitoring [28]

  • Regular follow-up imaging is indicated for asymptomatic patients with:
    • Mild stage B AS: every 3–5 years
    • Moderate stage B AS: every 1–2 years
    • Any stage C AS: every 6–12 months
  • On-demand imaging is indicated for patients with:
    • Any change in signs or symptoms
    • Conditions that have high hemodynamic/metabolic demands

Prophylactic antibiotics [28]

Aortic valve replacement (AVR) and repair [9]


The presence of exertional symptoms (dyspnea on exertion, angina pectoris, syncope) is an indication for surgery.


The choice of valve type and procedure approach involves shared decision-making based on multiple factors (e.g., anticoagulation risks, age, life expectancy). Refer candidates to a specialized heart valve team. [9]

  • Surgical AVR (SAVR) is recommended for patients with:
  • Transcatheter AVR (TAVR)
    • Recommended for patients with:
      • Age > 80 years
      • Life expectancy < 10 years
      • High or prohibitive surgical risk and predicted survival of > 12 months [9]
    • Emergency TAVR may be considered in certain patient groups. [30][31][32]
  • Percutaneous balloon valvuloplasty [9]
    • May be used in children, adolescents, and young adults
    • Limited role in older patients
    • Can consider as a bridging intervention in high-risk patients with stage D AS but overall benefit is questionable. [9]

Complications of aortic valve replacement [33][34][35]

Antithrombotic therapy after aortic valve replacement

Antithrombotic therapy for patients with prosthetic aortic valves [9]
Choice of agent Target INR Duration of therapy
Mechanical valve and no risk factors for thromboembolism
  • 2.5 (range 2.0–3.0)
  • Lifelong

Mechanical valve and ≥ 1 risk factor for thromboembolism

OR older generation mechanical valves

  • 3.0 (range 2.5–3.5)

Bioprosthetic valve with low risk of bleeding

  • 2.5 (range 2.0–3.0)

The safety and efficacy of DOACs in patients with mechanical valves have not been assessed and their use is not recommended. [9]

Dabigatran results in more thrombotic events and bleeding complications in patients with valvulopathy than warfarin. [9]

Complicationstoggle arrow icon

Critical complications of AS

The following can rapidly lead to decompensation and circulatory collapse in patients with severe AS:

Management [36]

Focus on acute stabilization while expediting definitive surgical treatment.

Do not delay surgical treatment of patients with AS and cardiogenic shock, rapid A-fib, and AHF.

Hemodynamic stabilization in severe AS [36]

Manage hemodynamically unstable patients with severe AS in consultation with a specialist while awaiting definitive surgical treatment.

Severe AS is a preload-dependent condition. Ensure adequate volume repletion prior to positive pressure ventilation to prevent circulatory collapse. [38]

Titrate diuretics and negative inotropic medications very carefully in severe AS as these can worsen cardiogenic shock and myocardial ischemia.

We list the most important complications. The selection is not exhaustive.

Acute management checklisttoggle arrow icon

The following applies to unstable patients with aortic stenosis:

Prognosistoggle arrow icon

  • Asymptomatic patients: Mortality rate is < 1% in a given year. [24]
  • Symptomatic patients: Mortality rate in the first 2 years is > 50% if left untreated. [39]

Referencestoggle arrow icon

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