Annals of Internal Medicine䊛

In the Clinic®

Aortic Screening
Stenosis Diagnosis

C
alcific aortic stenosis is the most common
cardiac valve lesion in developed coun-
tries (1, 2), and management is changing Treatment
because of recent advances in diagnostic and
treatment strategies. Modern management of
aortic valve disease is guided by more precise Practice Improvement
assessment of lesion severity and earlier inter-
vention, which can improve outcomes. Trans-
catheter therapies, used in the context of a
multidisciplinary care plan, are increasing the
options for aortic valve patients from just a
decade ago.

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Physician Writers doi:10.7326/AITC201701030

Faisal G. Bakaeen, MD
Todd K. Rosengart, MD
Blase A. Carabello, MD
CME Objective: To review current evidence for screening, diagnosis, treatment, and practice
improvement of aortic stenosis.
Funding Source: American College of Physicians.
Disclosures: Drs. Bakaeen, Rosengart, and Carabello, ACP Contributing Authors, have
nothing to disclose. Forms can be viewed at www.acponline.org/authors/icmje
/ConflictOfInterestForms.do?msNum=M16-2270.
With the assistance of additional physician writers, the editors of Annals of Internal
Medicine develop In the Clinic using MKSAP and other resources of the American
College of Physicians.
In the Clinic does not necessarily represent official ACP clinical policy. For ACP clinical
guidelines, please go to https://www.acponline.org/clinical_information/guidelines/.
© 2017 American College of Physicians

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 1. Nkomo VT, Gardin JM,
Skelton TN, Gottdiener JS,
Scott CG, Enriquez-Sarano
M. Burden of valvular
heart diseases: a
population-based study.
Lancet. 2006;368:1005-
11. [PMID: 16980116]
2. Thaden JJ, Nkomo VT,
Enriquez-Sarano M. The
global burden of aortic
stenosis. Prog Cardiovasc
Dis. 2014;56:565-71.
[PMID: 24838132]
3. Otto CM, Kuusisto J,
Reichenbach DD, Gown
AM, O’Brien KD. Charac-
terization of the early
lesion of ‘degenerative’
valvular aortic stenosis.
Histological and immuno-
histochemical studies.
Circulation. 1994;90:844-
53. [PMID: 7519131]
4. Badheka AO, Singh V,
Patel NJ, Arora S, Patel N,
Thakkar B, et al. Trends of
hospitalizations in the
United States from 2000
to 2012 of patients >60
years with aortic valve
Screening
disease. Am J Cardiol.
2015;116:132-41. [PMID:
25983278]
5. Stewart BF, Siscovick D,
Lind BK, Gardin JM, Gott-
diener JS, Smith VE, et al.
Clinical factors associated
with calcific aortic valve
disease. Cardiovascular
Health Study. J Am Coll
Cardiol. 1997;29:630-4.
[PMID: 9060903]
6. Osnabrugge RL, Mylotte
D, Head SJ, Van Mieghem
NM, Nkomo VT, LeReun
CM, et al. Aortic stenosis
in the elderly: disease
prevalence and number of
candidates for transcathe-
ter aortic valve replace-
ment: a meta-analysis and
modeling study. J Am Coll
Cardiol. 2013;62:1002-
12. [PMID: 23727214]
7. Coffey S, Cox B, Williams
MJ. The prevalence, inci-
dence, progression, and
risks of aortic valve sclero-
sis: a systematic review
and meta-analysis. J Am
Coll Cardiol. 2014;63:
2852-61. [PMID:
24814496]
8. Owens DS, Katz R, John-
son E, Shavelle DM,
Probstfield JL, Takasu J,
et al. Interaction of age
with lipoproteins as pre-
dictors of aortic valve
calcification in the Multi-
Ethnic Study of Atheroscle-
rosis. Arch Intern Med.
2008;168:1200-7. [PMID:
18541828]
9. Owens DS, Katz R, Takasu
J, Kronmal R, Budoff MJ,
O’Brien KD. Incidence and
progression of aortic valve
calcium in the Multi-Ethnic
Study of Atherosclerosis
(MESA). Am J Cardiol.
2010;105:701-8. [PMID:
20185020]
10. Schoen FJ. Mechanisms
of function and disease
of natural and replace-
ment heart valves. Annu
Rev Pathol. 2012;7:161-
83. [PMID: 21942526]
姝 2017 American College of Physicians
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The precise cause of calcific aor-
tic stenosis remains unknown.
Once considered a “degenera-
tive” disease, it is now believed
to develop from an active inflam-
matory process similar to that of
atherosclerosis (3). It occurs in
older persons; thus, its preva-
lence is increasing in light of the
aging population (1, 4). In the
Cardiovascular Health Study, the
prevalence of calcific aortic ste-
nosis was 1.3% in patients aged
65 to 74 years and 4% in those
aged 85 years or older (5). A
meta-analysis estimated the prev-
Which patients are at elevated
risk?
Many forms of aortic stenosis are
preceded by aortic sclerosis,
which is calcification and thicken-
ing of the valve without obstruc-
tion of ventricular outflow. Aortic
sclerosis is a common finding on
cardiac imaging, but each year
fewer than 2% of cases progress
to clinical aortic stenosis (7).
The most common form of aortic
stenosis (senile calcific aortic ste-
nosis) shares many of the risk fac-
tors of atherosclerosis, including
smoking; hypertension; hyperlip-
idemia; and, most important, ad-
vanced age (1, 2, 4, 5, 8, 9).
Congenitally abnormal aortic
valves are subject to abnormal me-
chanical stress and altered shear
stress, which in turn are associated
with accelerated and progressive
valve calcification. However, ge-
netic factors may also predispose
some patients to abnormal tissue
calcification (10). The most com-
mon congenitally abnormal aortic
valve is the bicuspid aortic valve,
which has an estimated prevalence
of 13.7 cases per 1000 persons
(11). On average, stenosis devel-
ops about 2 decades earlier in bi-
cuspid aortic valves than in normal
valves. The genetic causes of bi-
ITC2 In the Clinic
alence of aortic stenosis of any
severity at 12% in patients aged
75 years or older, and more than
a quarter of these cases were se-
vere (6). Other causes include
rheumatic valvular heart disease,
which is the leading cause in the
developing world.
The disorder is potentially lethal
when managed incorrectly, yet
proper management produces
gratifying results. This article up-
dates information on proper di-
agnosis and timing of interven-
tions for aortic stenosis.
cuspid valves are diverse, ranging
from complex inheritance in fami-
lies to sporadic cases without any
evidence of inheritance (12). Other
congenital causes of aortic steno-
sis, such as unicuspid valve, can
present in early childhood or
adolescence.
Rheumatic valve disease is still
common in developing coun-
tries. This disorder causes a char-
acteristic thickening of leaflet
edges and commissural fusion
that diminishes the valve orifice.
Affected patients remain at risk
for aortic stenosis many years
after the acute episode of rheu-
matic fever.
Rare causes include Williams syn-
drome, systemic lupus erythema-
tosus, and radiation therapy.
Mantle radiation greater than 30
Gy is associated with increased
risk, which usually arises more
than a decade after therapy and
is caused by diffuse fibrosis of
the valve cusps or leaflets with or
without calcification (13, 14).
Should clinicians screen patients
who have elevated risk?
Most asymptomatic patients do
not need to be screened for aor-
tic stenosis. However, it is reason-
able to use cardiac imaging in
patients with a heart murmur or
Annals of Internal Medicine 3 January 2017
 ejection click if valvular or struc-
tural heart disease is suspected
and to reevaluate such patients if
their clinical status changes (15,
16). Patients with conditions that
increase risk for aortic stenosis
How should clinicians screen
for aortic stenosis?
Transthoracic echocardiography
is the best screening and diag-
11. Mozaffarian D, Benjamin
nostic method. It is noninvasive
EJ, Go AS, Arnett DK,

may particularly benefit from car- and relatively inexpensive. It also Blaha MJ, Cushman M,
et al; American Heart
diac imaging if they have a new provides important information Association Statistics
Committee and Stroke
murmur or if there is any doubt about stenosis severity, cardiac Statistics Subcommittee.
about symptom status. In addi- function, and the presence and Heart disease and stroke
statistics—2015 update: a
tion, women with suspected aor- severity of left ventricular hyper- report from the American
Heart Association. Circu-
tic stenosis should be evaluated trophy (LVH) and other valve lation. 2015;131:e29-
before pregnancy. abnormalities. 322. [PMID: 25520374]
12. Prakash SK, Bossé Y,
Muehlschlegel JD, Mi-
chelena HI, Limongelli G,
Della Corte A, et al; BAV-
Screening... Most asymptomatic patients do not need to be screened Con Investigators. A
for aortic stenosis. Patients should have transthoracic echocardiography roadmap to investigate
the genetic basis of bi-
if they have symptoms or signs suggestive of valvular heart disease, cuspid aortic valve and
such as cardiac murmur or ejection click. Particular attention should be its complications: in-
sights from the Interna-
paid to those with risk factors for aortic stenosis, such as advanced age, tional BAVCon (Bicuspid
atherosclerotic disease, or a history of rheumatic heart disease. Aortic Valve Consortium).
J Am Coll Cardiol. 2014;
64:832-9. [PMID:
25145529]
CLINICAL BOTTOM LINE 13. Murbraech K, Wethal T,
Smeland KB, Holte H,
Loge JH, Holte E, et al.
Valvular dysfunction in
lymphoma survivors
treated with autologous

Diagnosis stem cell transplantation:

a national cross-sectional
study. JACC Cardiovasc
What symptoms or conditions second heart sound (S2); and a Imaging. 2016;9:230-9.
late-peaking systolic ejection [PMID: 26897666]
should prompt clinicians to 14. Ong DS, Aertker RA,
consider aortic stenosis? murmur (Supplement 1, avail- Clark AN, Kiefer T,
Hughes GC, Harrison JK,
The 3 cardinal symptoms of aor- able at www.annals.org) heard et al. Radiation-
tic stenosis are angina, dyspnea, best in the right upper sternal associated valvular heart
disease. J Heart Valve
and presyncope or syncope. border. Murmur severity alone Dis. 2013;22:883-92.
[PMID: 24597417]
Once these events occur, the nat- does not strongly correlate with 15. Douglas PS, Garcia MJ,
ural history of the disease disease severity, but as stenosis Haines DE, Lai WW,
Manning WJ, Patel AR,
changes dramatically: The risk for worsens, A2 becomes muffled or et al; American College
absent because the thickened of Cardiology Foundation
death increases from less than Appropriate Use Criteria
1% per year to 2% per month, leaflets no longer generate a Task Force. ACCF/ASE/
AHA/ASNC/HFSA/HRS/
such that 75% of symptomatic valve closure sound. Therefore, SCAI/SCCM/SCCT/SCMR
patients die within 3 years unless a single S2 is consistent with se- 2011 Appropriate Use
Criteria for Echocardiog-
they receive a valve replacement vere stenosis. A sustained force- raphy. A Report of the
American College of
(17–20). Sudden death is the ful apical impulse may be appre- Cardiology Foundation
most feared consequence of ig- ciated and shifted laterally Appropriate Use Criteria
Task Force, American
noring symptoms or waiting for because of LVH. Society of Echocardiogra-
phy, American Heart
them to develop in patients with What other clinical Association, American
severe aortic stenosis. Society of Nuclear Cardi-
manifestations should ology, Heart Failure
Society of America, Heart
What physical examination clinicians look for in patients Rhythm Society, Society
findings indicate possible aortic for Cardiovascular An-
with possible aortic stenosis? giography and Interven-
stenosis? The obstruction of blood flow tions, Society of Critical
Care Medicine, Society of
Physical examination of patients requires the left ventricle to gen- Cardiovascular Com-
puted Tomography, and
with aortic stenosis reveals the erate progressively greater pres- Society for Cardiovascular
characteristic findings of damp- sure to drive blood through the Magnetic Resonance
Endorsed by the Ameri-
ened and delayed carotid up- aortic valve. Pressure overload can College of Chest
stroke (parvus et tardus); an ab- leads to LVH, and LVH can cause Physicians. J Am Coll
Cardiol. 2011;57:1126-
sent aortic component (A2) of the symptoms. Concentric LVH, 66. [PMID: 21349406]

3 January 2017 Annals of Internal Medicine In the Clinic ITC3 姝 2017 American College of Physicians

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 Figure 1. Echocardiographic evaluation of aortic stenosis.

16. Nishimura RA, Otto CM,

Bonow RO, Carabello BA,
Erwin JP 3rd, Guyton RA,
et al; American College
of Cardiology/American
Heart Association Task
Force on Practice Guide-
lines. 2014 AHA/ACC
guideline for the man-
agement of patients with
valvular heart disease: a
report of the American
College of Cardiology/
American Heart Associa-
tion Task Force on Prac-
tice Guidelines. J Am
Coll Cardiol. 2014;63:
e57-185. [PMID:
24603191]
17. Carabello BA. Introduc-
tion to aortic stenosis.
Circ Res. 2013;113:179-
85. [PMID: 23833292]
18. Gohlke-Bärwolf C, Min-
ners J, Jander N, Gerdts
E, Wachtell K, Ray S,
et al. Natural history of
mild and of moderate Echocardiography reveals severe aortic stenosis, heavily calcified leaflets, and restricted valve
aortic stenosis—new opening. Doppler interrogation reveals peak jet velocity >5 m/s.
insights from a large
prospective European
study. Curr Probl Cardiol.
2013;38:365-409. which is most pronounced in the pressure leads to heart failure,
[PMID: 23972937] subendocardium, reduces coro- which is exacerbated by the myo-
19. Otto CM, Burwash IG,
Legget ME, Munt BI, nary blood flow reserve by 50% cardial fibrosis that accompanies
Fujioka M, Healy NL,
et al. Prospective study of or more. This decline occurs LVH and impairs systolic and dia-
asymptomatic valvular when elevated filling pressure stolic function. Aortic stenosis
aortic stenosis. Clinical,
echocardiographic, and compresses the subendocardium also reduces the degree to which
exercise predictors of
outcome. Circulation.
and capillary in-growth is inade- blood flow through the coronary
1997;95:2262-70. quate to supply the additional arteries can increase above their
[PMID: 9142003]
20. Ross J Jr, Braunwald E. cardiac mass. Thickened ventri- normal resting volume; this di-
Aortic stenosis. Circula- cles require greater diastolic minished flow reserve can con-
tion. 1968;38:61-7.
[PMID: 4894151] pressure for filling; increased tribute to angina.

姝 2017 American College of Physicians ITC4 In the Clinic Annals of Internal Medicine 3 January 2017

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 What laboratory tests and
imaging studies should
clinicians use to evaluate
patients with suspected aortic
stenosis?
Echocardiography of the aortic
valve is central to diagnosing aor-
tic stenosis (Figure 1). Severity is
most reliably determined by
echocardiographic hemody-
namic criteria, including Doppler
velocity greater than 4 m/s, aortic
valve area less than 1 cm2 (that is,
<0.6 cm2/m2 indexed to body
surface area), and a mean gradi-
ent greater than 40 mm Hg. A full
invasive hemodynamic study,
with retrograde catheterization of
the aortic valve and left ventricle
for pressure measurement, is no
longer recommended if noninva-
sive methods are adequate to
assess valve hemodynamics.
These measurement cutoffs are
all met in many patients with se-
vere aortic stenosis; however,
they are often inconsistent with
each other. For example, a pa-
tient with a peak aortic jet veloc-
ity of 3.5 m/s might have an aor-
tic valve area of 0.9 cm2, leaving
the practitioner to wonder which
diagnostic marker to use in defin-
ing severity. Thus, the clinician
should never base the diagnosis
on a single criterion—rather, it
requires considering the pa-
tient's history, physical examina-
tion findings, and all imaging
measurements. In difficult cases,
it may be necessary to consider
using invasive methods of hemo-
dynamic assessment.
What other diagnoses should
clinicians consider in patients
with possible aortic stenosis?
The differential diagnoses of a
systolic murmur include mitral or
tricuspid regurgitation; hypertro-
phic cardiomyopathy; and a hy-
perdynamic state related to in-
fection, fever, thyrotoxicosis, or
pregnancy.
3 January 2017 Annals of Internal Medicine
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Patients with confirmed aortic
stenosis are at elevated risk for
atherosclerotic lesions in various
vascular beds. Stenosis of the
posterior cerebral circulation
should be excluded, especially in
patients with presyncope or syn-
cope. Coronary artery disease
should be ruled out as part of the
work-up in patients with symptom-
atic aortic stenosis, especially if
angina is a prominent symptom.
When should clinicians
consider consulting a
cardiologist or other
specialist?
Referral to a cardiologist is rec-
ommended for all patients with
severe aortic stenosis, regardless
of symptoms, and for patients
with disease of uncertain severity.
In the latter case, additional test-
ing may be required to better
define hemodynamic severity
and to determine prognostic cri-
teria that will guide further man-
agement (Figure 2).
Low-dose dobutamine stress
echocardiography is particularly
useful if discordance among he-
modynamic measurements raises
doubts about severity, a problem
typically encountered in low-flow
(stroke volume index <35
mL/m2), low ejection fraction
(<0.50), low-gradient (<40 mm
Hg) cases with an aortic valve
area less than 1.0 cm2 (21). In
these situations, the question
arises whether the findings are
attributable to severe, long-
standing aortic stenosis that has
damaged the left ventricle or to a
left ventricle that has been dam- 21. Pibarot P, Dumesnil JG.
Low-flow, low-gradient
aged by nonvalvular cardiomy- aortic stenosis with nor-
opathy and cannot generate suf- mal and depressed left
ventricular ejection frac-
ficient force to open a mildly tion. J Am Coll Cardiol.
2012;60:1845-53.
stenotic valve (“pseudo aortic ste- [PMID: 23062546]
nosis”). A large increase in stroke 22. Clavel MA, Pibarot P,
Dumesnil JG. Paradoxi-
volume in response to the inotro- cal low flow aortic valve
stenosis: incidence, eval-
pic effect of dobutamine, coupled uation, and clinical sig-
with only a small increase in jet nificance. Curr Cardiol
Rep. 2014;16:431.
velocity (gradient), greatly in- [PMID: 24343152]
In the Clinic ITC5 姝 2017 American College of Physicians
 Figure 2. Algorithm of contemporary aortic stenosis management and American College of Cardiology/American
Heart Association guidelines summary.

Diagnosis of
valve disease

Hemodynamic Severity
Severe
Aortic Stenosis or uncertain No Close follow-up
Mild: Vmax 2.0–2.9 m/s severity?
Moderate: Vmax 3.0–3.9 m/s
Severe: Vmax ≥4 m/s

Yes
TTE Frequency

Years: Mild hemodynamic

Early referral severity

1–3 years: Moderate

Heart team assessment hemodynamic severity

6–12 months: Severe

hemodynamic severity
Refine assessment of severity and hemodynamic
impact on LV (consider stress echocardiography, Repeated TTE indicated for
invasive hemodynamic measurements at time of changing signs or symptoms
coronary angiography)

Severe disease confirmed, Watchful waiting

plus symptomatic/inducible
symptoms, LV dysfunction, No
or abnormal LV dimensions? A valve center of excellence
Physiologic Considerations with proven outcomes for
STS score early intervention
Disease not captured by STS score
Frailty assessment Yes
Life expectancy

Anatomical Considerations Evaluate anatomical suitability and physiologic risk

Porcelain aorta/hostile
mediastinum
Adequacy of access and
suitability of aortic root anatomy Surgical/transcatheter intervention
(if TAVR contemplated)

Aortic Stenosis
Class I
Severe, symptomatic
Severe, asymptomatic with reduced EF
TAVR for patients at prohibitive surgical risk

Class IIa
Severe, asymptomatic, critical (velocity ≥5 m/s)
Severe, occult/inducible symptoms
Symptomatic with low-flow/low-gradient aortic stenosis
with stress induction or clear demonstration of
significant obstructive hemodynamics
Moderate, at time of surgery for another indication
TAVR for patients at high surgical risk

Class llb
Severe; asymptomatic but rapidly progressing

Note: All recommendations relating to the timing of

intervention are based on level of evidence B (mainly
from observational studies) or C (expert opinion).

Accurate assessment of valve lesion severity and timely referral and intervention are crucial. EF = ejection fraction; LV = left ventricle; RF =
regurgitant fraction; STS = Society of Thoracic Surgeons; TAVR = transcatheter aortic valve replacement; TTE = transthoracic echocardiogra-
phy; Vmax = maximum velocity.

creases the calculated aortic valve of the lack of stenosis. In contrast,

area, making pseudo aortic steno- patients with truly severe stenosis
sis the appropriate diagnosis. In have a fixed aortic valve area so
such cases, valve replacement is that jet velocity and stroke volume
unlikely to be beneficial because increase in tandem, confirming

姝 2017 American College of Physicians ITC6 In the Clinic Annals of Internal Medicine 3 January 2017

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 Figure 3. Transcatheter aortic valve replacement: preintervention multidetector computed tomography imaging
and valve deployment.

LMCA = left main coronary artery; LVOT = left ventricular outflow tract. A. Measurement of valve area by planimetry. B. Sizing the aortic
annulus. C. Left main coronary clearance. D. Evaluation of vascular access. E. Transcatheter aortic valve in position across the annulus
immediately before deployment.

that stenosis is severe; these pa- cavity and impairs filling, thus
tients do benefit from aortic valve reducing stroke volume (22).
replacement. Although these patients have a 23. Le Ven F, Freeman M,
poorer prognosis after aortic Webb J, Clavel MA,
Paradoxical low flow can occur valve replacement than do pa- Wheeler M, Dumont É,
et al. Impact of low flow
tients with normal flow (23), re-
with preserved left ventricular placement still has a better
on the outcome of high-
risk patients undergoing
function when pronounced left outcome than medical transcatheter aortic valve
ventricular concentric remodel- replacement. J Am Coll
management. Cardiol. 2013;62:782-8.
ing shrinks the left ventricular [PMID: 23770162]

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 Multidetector computed tomog-
raphy has assumed an important
role in the work-up of patients be-
ing considered for transcatheter
aortic valve replacement (TAVR).
This imaging method is useful for
assessing the severity of valve cal-
cification and measuring aortic
annular area (Figure 3). Heavy
valve calcification helps establish
the diagnosis of severe aortic ste-
nosis when other data are incon-
sistent and adds prognostic infor-
mation (24). Likewise, B-type
natriuretic peptide levels can be
useful when the severity of aortic
stenosis and its effects on the left
ventricle remain in question.

24. Clavel MA, Pibarot P,

Messika-Zeitoun D, Ca- Diagnosis... Transthoracic echocardiography is the method of choice
poulade R, Malouf J, for diagnosing and estimating the severity of aortic stenosis. However,
Aggarval S, et al. Impact
of aortic valve calcifica-
determining severity requires considering the history, physical examina-
tion, as measured by tion findings, and all imaging measurements. In difficult cases—for ex-
MDCT, on survival in ample, when standard indicators (such as aortic valve area and the gra-
patients with aortic ste-
nosis: results of an inter- dient across the valve) yield discordant information—further study, such
national registry study. J as invasive hemodynamic assessment, may be necessary.
Am Coll Cardiol. 2014;
64:1202-13. [PMID:
25236511]
25. Teo KK, Corsi DJ, Tam
JW, Dumesnil JG, Chan
CLINICAL BOTTOM LINE
KL. Lipid lowering on
progression of mild to
moderate aortic stenosis:
meta-analysis of the
randomized placebo-
controlled clinical trials
on 2344 patients. Can J
Cardiol. 2011;27:800-8.
[PMID: 21742465]
Treatment
26. Kapadia SR, Leon MB, What nondrug therapies been shown to slow the progres-
Makkar RR, Tuzcu EM,
Svensson LG, Kodali S, should clinicians recommend? sion of aortic stenosis (25).
et al; PARTNER trial in- Patients with moderate-to-severe
vestigators. 5-year out- When should patients be
comes of transcatheter or severe aortic stenosis should
aortic valve replacement considered for valve
compared with standard avoid strenuous physical activity
replacement?
treatment for patients and sports with demands for
with inoperable aortic Development of symptoms is the
stenosis (PARTNER 1): a high muscular effort.
randomised controlled most important trigger for aortic
trial. Lancet. 2015;385: What medications should
2485-91. [PMID:
valve replacement in patients with
25788231] clinicians use for treatment? severe aortic stenosis. The death
27. Duke Clinical Research
Institute. Adult Cardiac No drug has been proved to re- rate after symptoms arise is 2% per
Surgery Database Execu-
tive Summary: 10 Years,
verse aortic stenosis; definitive month and higher (20, 26), similar
STS Period Ending 06/ management requires mechanical to the perioperative mortality risk
30/2015. 2015. Ac-
cessed at www.sts.org intervention. However, all patients associated with contemporary iso-
/sites/default/files lated surgical aortic valve replace-
/documents/2015Har-
with aortic stenosis should receive
vest3 appropriate medical therapy for ment (SAVR) (27, 28), and the rate
_ExecutiveSummary.pdf
on 27 September 2016. associated risk factors or concur- increases greatly over the ensuing
28. Thourani VH, Suri RM, rent disease, including coronary months. Thus, delays in symptom
Gunter RL, Sheng S,
O’Brien SM, Ailawadi G, artery disease, atrial fibrillation, recognition and intervention can
et al. Contemporary
real-world outcomes of and diabetes mellitus. Likewise, jeopardize survival.
surgical aortic valve re- patients with heart failure should
placement in 141,905
receive appropriate drug therapy. Because symptoms may be unrec-
low-risk, intermediate-
risk, and high-risk pa- ognized in up to half of “asymp-
tients. Ann Thorac Surg.
2015;99:55-61. [PMID: In patients with aortic stenosis, tomatic” patients with severe aortic
25442986] medication for hypertension stenosis (29), unmasking symp-
29. Rafique AM, Biner S, Ray
I, Forrester JS, Tolstrup K, should be started at low doses toms with stress testing may be
Siegel RJ. Meta-analysis
of prognostic value of
and gradually titrated upward as useful in patients suspected of
stress testing in patients needed, with frequent clinical having more advanced disease,
with asymptomatic se-
vere aortic stenosis. Am J monitoring. Treating concomi- who may therefore be at greater
Cardiol. 2009;104: tant hyperlipidemia is recom- risk for adverse cardiac events.
972-7. [PMID:
19766766] mended, but statins have not Stress testing is safe if done by

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 experienced operators in appro-
priately selected patients. Exercise
testing is preferable to pharmaco-
logic stress testing for assessing
risk in asymptomatic patients (30)
but involves too much risk in
overtly symptomatic patients
with severe aortic stenosis.
In addition, in asymptomatic pa-
tients with severe aortic stenosis,
the short- to mid-term probability
of not needing valve replacement
or not experiencing cardiac death
is low, especially when jet velocity
exceeds 5.0 m/s or aortic valve
area is less than 0.6 cm2 (2, 31).
For example, most patients with a
peak jet velocity of 4 m/s require
valve replacement within 2 years,
and most patients with a jet veloc-
ity exceeding 5 m/s require aortic
valve replacement within 1 year
(19, 31).
As a result, the role of surgery in
truly asymptomatic patients with
severe aortic stenosis is emerg-
ing because they are at imminent
risk for disease progression and
their risk for valve-related ad-
verse events during watchful
waiting outweighs the risk associ-
ated with intervention. For exam-
ple, the American College of
Cardiology/American Heart As-
sociation (ACC/AHA) guidelines
recommend valve replacement
for low-surgical-risk patients with
very severe stenosis (velocity ≥5
m/s or a mean pressure gradient
≥60 mm Hg), regardless of symp-
toms. This is a class IIa recom-
mendation (“reasonable to per-
form”) (16).
Another important consideration
in the timing of the intervention is
whether the hemodynamic ab-
normalities associated with aortic
stenosis have resulted in left ven-
tricular dysfunction. In addition to
symptom severity (32), several
other factors— compensatory LVH
(33), myocardial fibrosis (34), and
depressed left ventricular func-
tion (32)—are associated with
3 January 2017 Annals of Internal Medicine
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greater operative mortality. How-
ever, despite this increased risk,
surgery seems to improve out-
comes in patients with left ven-
tricular dysfunction (35). There-
fore, the ACC/AHA guidelines
recommend aortic valve replace-
ment in patients who are asymp-
tomatic but have severe stenosis
and left ventricular dysfunction.
This is a class I recommendation
(“should be performed”) (16, 35).
Newer prognostic indices are
emerging for evaluating and stag-
ing patients with aortic stenosis.
Data derived from cardiac mag-
netic resonance imaging, echocar-
diographic speckle tracking (36,
37), and biochemical markers
could potentially inform interven-
tion timing, but these methods
require further study before firm
conclusions can be drawn about
their clinical usefulness.
Which patients should have
SAVR, and which should have
TAVR?
Surgical aortic valve replacement
is the traditional, definitive, and
time-tested therapy for aortic ste-
nosis. Data from the Society of
Thoracic Surgeons (STS) Adult
Cardiac Surgery Database show
that approximately 49 000 SAVRs
were performed in 2015, and
more than 29 000 were isolated
procedures (27). There has been
a dramatic shift toward using bio-
prosthetic valves instead of me-
chanical valves (38). In a 2006 –
2011 study of Medicare
beneficiaries aged 65 years or
older who had aortic valve re-
placement, 71% received bio-
prosthetic valves (39).
Traditional SAVR through full
sternotomy remains the most
common form of aortic valve re-
placement. Minimal-access pro-
cedures through partial sternot-
omy or mini-thoracotomy have
become increasingly popular for
isolated SAVR (Figure 4). Most of
the data are derived from obser-
In the Clinic ITC9
30. Henri C, Piérard LA,
Lancellotti P, Mongeon
FP, Pibarot P, Basmad-
jian AJ. Exercise testing
and stress imaging in
valvular heart disease.
Can J Cardiol. 2014;30:
1012-26. [PMID:
25151284]
31. Rosenhek R, Zilberszac R,
Schemper M, Czerny M,
Mundigler G, Graf S,
et al. Natural history of
very severe aortic steno-
sis. Circulation. 2010;
121:151-6. [PMID:
20026771]
32. O’Brien SM, Shahian
DM, Filardo G, Ferraris
VA, Haan CK, Rich JB,
et al; Society of Thoracic
Surgeons Quality Mea-
surement Task Force. The
Society of Thoracic Sur-
geons 2008 cardiac
surgery risk models: part
2—isolated valve surgery.
Ann Thorac Surg. 2009;
88:S23-42. [PMID:
19559823]
33. Duncan AI, Lowe BS,
Garcia MJ, Xu M, Gillinov
AM, Mihaljevic T, et al.
Influence of concentric
left ventricular remodel-
ing on early mortality
after aortic valve replace-
ment. Ann Thorac Surg.
2008;85:2030-9. [PMID:
18498815]
34. Dweck MR, Joshi S,
Murigu T, Alpendurada
F, Jabbour A, Melina G,
et al. Midwall fibrosis is
an independent predic-
tor of mortality in pa-
tients with aortic steno-
sis. J Am Coll Cardiol.
2011;58:1271-9. [PMID:
21903062]
35. Connolly HM, Oh JK,
Orszulak TA, Osborn SL,
Roger VL, Hodge DO,
et al. Aortic valve replace-
ment for aortic stenosis
with severe left ventricu-
lar dysfunction. Prognos-
tic indicators. Circulation.
1997;95:2395-400.
[PMID: 9170402]
36. Kusunose K, Goodman
A, Parikh R, Barr T, Agar-
wal S, Popovic ZB, et al.
Incremental prognostic
value of left ventricular
global longitudinal strain
in patients with aortic
stenosis and preserved
ejection fraction. Circ
Cardiovasc Imaging.
2014;7:938-45. [PMID:
25320287]
37. Li CM, Li C, Bai WJ,
Zhang XL, Tang H, Qing
Z, et al. Value of three-
dimensional speckle-
tracking in detecting left
ventricular dysfunction in
patients with aortic valvu-
lar diseases. J Am Soc
Echocardiogr. 2013;26:
1245-52. [PMID:
23993696]
姝 2017 American College of Physicians
 38. Brown JM, O’Brien SM,
Figure 4. Minimally invasive aortic valve replacement via partial upper
Wu C, Sikora JA, Griffith sternotomy.
BP, Gammie JS. Isolated
aortic valve replacement
in North America com-
prising 108,687 patients
in 10 years: changes in
risks, valve types, and
outcomes in the Society
of Thoracic Surgeons
National Database. J
Thorac Cardiovasc Surg.
2009;137:82-90. [PMID:
19154908]
39. Du DT, McKean S, Kel-
man JA, Laschinger J,
Johnson C, Warnock R,
et al. Early mortality after
aortic valve replacement
with mechanical pros-
thetic vs bioprosthetic
valves among Medicare
beneficiaries: a
population-based cohort
study. JAMA Intern Med.
2014;174:1788-95.
[PMID: 25221895]
40. Brown ML, McKellar SH,
Sundt TM, Schaff HV.
Ministernotomy versus
conventional sternotomy
for aortic valve replace-
ment: a systematic re-
view and meta-analysis. vational studies and support the sick” to refer for specialty care, in-
J Thorac Cardiovasc Surg. efficacy and safety of these pro- cluding surgical evaluation.
2009;137:670-679.e5.
[PMID: 19258087] cedures in selected patients at
41. Lee R, Li S, Rankin JS,
centers with relevant expertise Aortic balloon valvuloplasty,
O’Brien SM, Gammie JS,
Peterson ED, et al; Soci- (40). New, sutureless valves with although useful as a bridge to
ety of Thoracic Surgeons
an anchoring mechanism based more definitive treatments, is asso-
Adult Cardiac Surgical
Database. Fifteen-year
on an expandable stent facilitate ciated with poor outcomes as a
outcome trends for valve
surgery in North Amer- implantation, making them par- stand-alone therapy in adult pa-
ica. Ann Thorac Surg.
ticularly well-suited for minimal- tients with severe aortic stenosis
2011;91:677-84. [PMID:
21352979] access surgery because placing (43). It can be a palliative measure in
42. Bakaeen FG, Chu D,
Ratcliffe M, Gopaldas RR, multiple sutures at a surgical site selected patients who are not candi-
Blaustein AS, Venkat R,
with minimal exposure can be dates for definitive therapy. Its main
et al. Severe aortic steno-
sis in a veteran popula- difficult and time-consuming. limitations are that it only temporar-
tion: treatment consider- ily relieves stenosis and can cause or
ations and survival. Ann
Thorac Surg. 2010;89: Perioperative outcomes of SAVR worsen aortic regurgitation.
453-8. [PMID: are tracked closely at the national
20103320]
43. Nwaejike N, Mills K, level and have improved sub- Transcatheter aortic valve replace-
Stables R, Field M. Bal-
stantially over time (27, 41). Ac- ment has emerged as a therapeu-
loon aortic valvuloplasty
as a bridge to aortic valve cording to recent reports from tic option for an increasing num-
surgery for severe aortic
the STS database, the observed ber of patients with aortic stenosis.
stenosis. Interact Cardio-
vasc Thorac Surg. 2015; surgical mortality is less than 3% The first commercially available
20:429-35. [PMID:
25487231] overall (27, 28) and less than 2% transcatheter valve entered prac-
44. Holmes DR Jr, Nishimura
in low-risk patients (28). The STS tice in the United States in late
RA, Grover FL, Brindis
RG, Carroll JD, Edwards risk calculator seems to be the 2011, and approximately 13 000
FH, et al; STS/ACC TVT
most robust in predicting the risk of these procedures were done in
Registry. Annual out-
comes with transcatheter
of aortic valve replacement, al- 2014 (44). Randomized clinical
valve therapy: from the
STS/ACC TVT Registry. though experienced surgeons rou- trials show TAVR to be superior to
Ann Thorac Surg. 2016;
tinely outperform that risk (32). medical therapy in inoperable pa-
101:789-800. [PMID:
27175453] tients (45, 46), equal or superior to
45. Leon MB, Smith CR, Traditionally, only 40% to 60% of SAVR in high-risk patients (47, 48),
Mack M, Miller DC, Mo-
ses JW, Svensson LG, patients with severe aortic stenosis and now equal or even superior to
et al; PARTNER Trial
Investigators. Transcathe- have SAVR (42). Common reasons SAVR in intermediate-risk patients
ter aortic-valve implanta- for avoiding this procedure in- (45). Patients particularly well-
tion for aortic stenosis in
patients who cannot clude advanced age; severe co- suited for TAVR include those with
undergo surgery. N Engl morbidities; and frailty that ren- advanced age; extracardiac co-
J Med. 2010;363:1597-
607. [PMID: 20961243] ders patients “inoperable” or “too morbidities, including renal, liver,

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 Table. 2014 American College of Cardiology/American Heart Association Staging of Valvular Heart
Disease—Aortic Stenosis
Stage Definition Hemodynamic Severity and Effect Description
A At risk No significant hemodynamic Risk factors are aortic sclerosis, bicuspid aortic valve or other
abnormality or effect congenital valve anomaly, and history of rheumatic fever
B Progressive Mild or moderate aortic stenosis with Asymptomatic; mild-to-moderate leaflet calcification, some
normal LVEF, possible early diastolic restriction of leaflet motion, rheumatic valve changes with
dysfunction thickening of leaflets, and fusion of commissures
C Asymptomatic C1: Severe aortic stenosis in which the Asymptomatic; severe calcification and severe restriction of
severe left or right ventricle remains leaflet motion
compensated, LVEF ≥0.50
C2: Severe aortic stenosis with
decompensation of the left or right
ventricle, LVEF <0.50
LV hypertrophy and diastolic
dysfunction
D Symptomatic Severe aortic stenosis with or without Symptomatic + stage C features
severe ventricular decompensation and
normal or severely depressed LV
function

LV = left ventricular; LVEF = left ventricular ejection fraction.

and lung disease; and anatomical A newer application of TAVR is

factors that would complicate an
open surgical approach, such as a
heavily calcified (or “porcelain”)
aorta, a mediastinum exposed to
previous chest radiation, or vital
structures at risk for injury during
sternotomy.
Transfemoral arterial access to
the aortic valve is the default ap-
proach for TAVR (Figure 3 and
Supplement 2, available at www
.annals.org). When femoral arte-
rial access is contraindicated by
valve deployment into degener-
ated or malfunctioning biopros-
thetic valves, known as valve-in-
valve implantation. According to 46. Popma JJ, Adams DH,
Reardon MJ, Yakubov
the Valve-in-Valve International SJ, Kleiman NS, Heiman-
Data Registry (50), postoperative sohn D, et al; CoreValve
United States Clinical
survival rates are lower among Investigators. Transcathe-
ter aortic valve replace-
patients with predominant surgi-
ment using a self-
cal valve stenosis or small bio- expanding bioprosthesis
in patients with severe
prostheses (≤21 mm). The latter aortic stenosis at extreme
risk for surgery. J Am
finding is probably explained by
Coll Cardiol. 2014;63:
patient–prosthesis mismatch 1972-81. [PMID:
24657695]
compounded by the insertion of 47. Adams DH, Popma JJ,

severe calcification, marked tor- a replacement valve into a small Reardon MJ. Transcathe-
ter aortic-valve replace-
tuosity, severe atherosclerosis, bioprosthesis. ment with a self-
expanding prosthesis
or small vessel size, alternatives Current TAVR devices have com- [Letter]. N Engl J Med.
2014;371:967-8. [PMID:
include transapical, trans– mon limitations, including a more 25184874]
ascending aortic, transsubclavian, frequent association with paraval-
48. Smith CR, Leon MB,
Mack MJ, Miller DC,
and transcarotid approaches. vular leak and permanent pace- Moses JW, Svensson LG,
et al; PARTNER Trial
Information on TAVR outcomes maker implantation than surgi- Investigators. Transcathe-
ter versus surgical aortic-
in patients with bicuspid aortic cally implanted valves. valve replacement in
high-risk patients. N Engl
valve stenosis is limited. The cur- Nonetheless, technologic ad- J Med. 2011;364:2187-
rent global experience consists vances are occurring rapidly, pro- 98. [PMID: 21639811]
49. Zhao ZG, Jilaihawi H,
of procedures done on a se- ducing lower-profile devices that Feng Y, Chen M. Trans-
lected subset of patients—for ex- are progressively easier and safer catheter aortic valve
implantation in bicuspid
ample, fewer than 2% of those in to deploy and cause less paraval- anatomy. Nat Rev Car-
diol. 2015;12:123-8.
the U.S. registry—and should not vular leak, thus altering their risk– [PMID: 25311233]
be extrapolated to the broader benefit ratio. Although data on 50. Dvir D, Webb JG, Bleiz-
iffer S, Pasic M, Waks-
population without additional the long-term efficacy and safety man R, Kodali S, et al;
Valve-in-Valve Interna-
study (49). Moderate or severe of SAVR are abundant, more tional Data Registry In-
paravalvular aortic regurgitation long-term data on TAVR are vestigators. Transcatheter
aortic valve implantation
is more common in patients with needed. In addition, the useful- in failed bioprosthetic
bicuspid aortic valve than in ness of TAVR in lower-risk pa- surgical valves. JAMA.
2014;312:162-70.
those with tricuspid aortic valve. tients remains undetermined. [PMID: 25005653]

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51. Yechoor P, Blaustein AS,
Bakaeen FG, Cornwell
LD, Coselli JS, LeMaire
SA, et al. The natural
history of moderate
aortic stenosis in a vet-
eran population. J Thorac
Cardiovasc Surg. 2013;
145:1550-3. [PMID:
22664178]
52. Michelena HI, Khanna
AD, Mahoney D, Mar-
garyan E, Topilsky Y, Suri
RM, et al. Incidence of
aortic complications in
patients with bicuspid
aortic valves. JAMA.
2011;306:1104-12.
[PMID: 21917581]
53. Rahimtoola SH. Choice
of prosthetic heart valve
in adults an update. J
Am Coll Cardiol. 2010;
55:2413-26. [PMID:
20510209]
54. Brennan JM, Edwards
FH, Zhao Y, O’Brien S,
Booth ME, Dokholyan
RS, et al; DEcIDE AVR
(Developing Evidence to
Inform Decisions about
Effectiveness–Aortic Valve
Replacement) Research
Team. Long-term safety
and effectiveness of
mechanical versus bio-
logic aortic valve prosthe-
ses in older patients:
results from the Society
of Thoracic Surgeons
Adult Cardiac Surgery
National Database. Circu-
lation. 2013;127:1647-
55. [PMID: 23538379]
55. Chiang YP, Chikwe J,
Moskowitz AJ, Itagaki S,
Adams DH, Egorova NN.
Survival and long-term
outcomes following
bioprosthetic vs mechan-
ical aortic valve replace-
ment in patients aged
50 to 69 years. JAMA.
2014;312:1323-9.
[PMID: 25268439]
姝 2017 American College of Physicians
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Natural History of Aortic
Sclerosis*
Aortic sclerosis
Common finding on cardiac
imaging, but <2% of cases
of sclerosis progress to
clinical aortic stenosis each
year (7)
Aortic stenosis
Hemodynamic progression is
variable (2, 18, 19)
Mean increase in velocity of
0.2– 0.3 m/s, mean gradient
of 3–7 mm Hg, and
decrease in valve area of
0.03– 0.1 cm2/y
Affected by baseline hemody-
namic severity, age, degree
of valve calcification, and
CAD
The main predictors of clinical
outcomes are aortic stenosis
severity, symptom onset,
and LV dysfunction (2, 20)
The natural history of severe,
symptomatic aortic stenosis
is poor (2): 1-y mortality is
approximately 50% and 5-y
mortality is >90% (26) in
patients for whom AVR
creates prohibitive risk
Even among asymptomatic
patients with moderate or
severe aortic stenosis, <50%
are alive and free of AVR
≥2 y after surgery (2, 51)
AVR = aortic valve replacement;
CAD = coronary artery disease;
LV = left ventricular.
* Numbers in parentheses are
references.
How often should clinicians see
patients in follow-up (before and
after valve replacement), and
what should follow-up entail?
The degree of aortic stenosis
progresses over time and re-
quires close monitoring to assess
whether symptoms have begun
or the left ventricle has become
ITC12 In the Clinic
dysfunctional (2, 18 –20, 51) (see
the Box). Rigorous follow-up is
essential (Figure 2) for patients
who currently do not meet the
threshold for intervention to
avoid any delay should interven-
tion become necessary. Aortic
stenosis generally progresses
more rapidly in older patients
and those with more hemody-
namically severe stenosis or
denser leaflet calcification (18)
(Table). Patients with bicuspid
aortic valve are also at higher risk
for progression (7, 52).
In patients with known aortic ste-
nosis, repeated transthoracic
echocardiography is warranted
whenever signs or symptoms
change. This procedure is also
appropriate if hemodynamic de-
mand is anticipated to increase in
such stressful situations as sur-
gery, pregnancy, or severe sys-
temic infection.
Yearly follow-up with a routine
physical and detailed cardiovas-
cular assessment is generally rec-
ommended after aortic valve re-
placement. In addition, patients
who develop any new cardiac
symptoms should be examined to
rule out malfunction of the valve
prosthesis. Echocardiography is
warranted in these patients. It is
also warranted annually in patients
with bioprosthetic valves, starting
5 to 10 years after valve replace-
ment. Bioprosthetic valves are
prone to structural degeneration,
which is strongly correlated with
the patient's age at implantation
and increases risk for reoperation
(53). In contrast, mechanical valves
are associated with an elevated
risk for major bleeding events in
light of the lifelong requirement
for anticoagulation (54, 55).
Laboratory testing (including
chemistry, lipid profile, and pro-
thrombin time for patients receiv-
ing warfarin) and electrocardiog-
raphy are part of the routine
checkup. Chest radiography or
Annals of Internal Medicine 3 January 2017
 additional testing may be dic-
tated by the patient's symptoms.
When should clinicians
hospitalize patients with aortic
stenosis?
Patients with decompensated
heart failure should be admitted to
the hospital for medical optimiza-
tion ahead of definitive therapy.
Judicious intravenous diuresis is a
cornerstone strategy. Patients with
low cardiac output may require
inotropic support or mechanical
circulatory support to maintain
organ perfusion and reverse organ
dysfunction. Balloon aortic valvulo-
plasty may also be considered for
patients without significant aortic
regurgitation. Admission should
also be considered for other pa-
tients with rapidly progressive or
unstable symptoms.
When should clinicians consult
a cardiologist or other
specialist for treating patients
with aortic stenosis?
Patients with severe aortic steno-
sis or aortic stenosis of uncertain
severity should be referred to a
cardiologist or other specialist for
further evaluation and treatment.
The concept of a multidisciplinary
heart valve team consisting of (at a
minimum) cardiac surgeons, inter-
ventional and noninterventional
cardiologists, and cardiovascular
imaging specialists began to crys-
talize in recent years because of
the increasing complexity of car-
diovascular patients' conditions
and the emergence of new treat-
ment options, some of which re-
quire skill sets across different
specialties.

Treatment... Definitive management of aortic stenosis requires me-

chanical intervention. However, all patients with aortic stenosis should
receive appropriate medical therapy for associated risk factors or con-
current disease. Patients with severe stenosis should be evaluated for
valve replacement when symptoms of angina, heart failure, or syncope
or presyncope arise. Patients should be evaluated for valve replace-
ment when they are asymptomatic but have a jet velocity greater than
5.0 m/s, an aortic valve area less than 0.6 cm2, or left ventricular dys-
function. Modern management of aortic stenosis is characterized by
advanced diagnostics and multidisciplinary care, which translate into
improved outcomes from earlier referral and more treatment options.
These options continue to evolve rapidly, offering new avenues to pre-
viously untreatable patients but also requiring providers to keep
abreast of them. Surgical aortic valve replacement remains the corner-
stone treatment for patients with severe aortic stenosis who are at ac-
ceptable surgical risk, and TAVR is emerging as an important treatment
method for selected patients at moderate or increased surgical risk.
With time, more data will allow us to determine the value of TAVR in
lower-risk patients and the long-term outcomes associated with it.

CLINICAL BOTTOM LINE

How do stakeholders evaluate
the quality of care for patients
with aortic stenosis?
Multiprofessional guidelines are
the basis for identifying
evidence-based measures that
can improve patient care. Many
Practice Improvement
of the recommendations
in the 2014 ACC/AHA guide-
lines (16) are included in this
document and address the
spectrum of aortic valve care
from diagnosis to treatment and
follow-up.

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56. Shahian DM, He X, Ja-
cobs JP, Rankin JS,
Welke KF, Filardo G,
et al. The Society of Tho-
racic Surgeons Isolated
Aortic Valve Replacement
(AVR) Composite Score: a
report of the STS Quality
Measurement Task Force.
Ann Thorac Surg. 2012;
94:2166-71. [PMID:
23127768]
57. American College of
Cardiology. Choosing
Wisely: Five Things Phy-
sicians and Patients
Should Question. 2015.
Accessed at www.choos-
ingwisely.org/wp-content
/uploads/2015/02/ACC
-Choosing-Wisely-List.pdf
on 12 September 2016.
58. Wood DE, Mitchell JD,
Schmitz DS, Grondin SC,
Ikonomidis JS, Bakaeen
FG, et al. Choosing wise-
ly: cardiothoracic sur-
geons partnering with
patients to make good
health care decisions.
Ann Thorac Surg. 2013;
95:1130-5. [PMID:
23434251]
姝 2017 American College of Physicians
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With regard to formal surgical
metrics of quality, the STS Iso-
lated Aortic Valve Replacement
composite score is based on
perioperative outcomes, includ-
ing risk-standardized mortality
and any-or-none risk-standard-
ized morbidity (sternal infection,
reoperation, stroke, renal failure,
or prolonged ventilation) (56).
The composite score is then used
to rank programs with a 1- to
3-star rating.
What do professional
organizations recommend with
regard to care of patients with
aortic stenosis?
Echocardiography of the aortic
valve is central to diagnosis. Ac-
cording to the ACC/AHA guide-
lines and multisocietal appropri-
ateness criteria, echocardiography
is indicated in the initial evaluation
of patients in whom a reasonable
suspicion of valvular or structural
heart disease exists (15, 16).
The 2014 ACC/AHA guidelines
introduced a new staging system
for the clinical severity of valvular
heart disease that takes into ac-
count hemodynamic severity of
the lesion, symptoms, and ven-
tricular function and dimensions
(Table). Further risk stratification
within this staging system incor-
porates findings on leaflet open-
ing and morphologic characteris-
tics (for example, degree of
calcification, bicuspid aortic
valve, and rheumatic features)
and pulmonary hypertension
(16). The staging system stan-
dardizes tracking of aortic steno-
sis progression, emphasizing im-
portant prognostic indicators that
guide patient management and
the timing of intervention.
The ACC recommends against
performing echocardiography as
ITC14
routine follow-up for mild, asymp-
tomatic, native valve disease in
adult patients with no change in
signs or symptoms (57).
With regard to the choice of
valve for patients who meet indi-
cations for intervention (Figure
2), the ACC/AHA guidelines
make the following 2 sets of rec-
ommendations (16).
First, the choice of prosthetic
valve should involve a shared
decision-making process, ac-
counting for the patient's values
and preferences and including
comprehensive discussions
about the 2 primary consider-
ations in choosing between me-
chanical and tissue valves—the
risks of anticoagulant therapy
versus the risk for reoperation.
Bioprosthesis is recommended
for SAVR in patients of any age if
anticoagulant therapy is contrai-
ndicated, cannot be managed
appropriately, or is not desired.
Mechanical prosthesis is recom-
mended in patients at risk for ac-
celerated structural valve deterio-
ration, including young age and
hyperparathyroidism.
Second, SAVR is recommended in
patients with low or intermediate
surgical risk, whereas TAVR is rec-
ommended in patients for whom
SAVR poses prohibitive risk and
whose predicted post-TAVR sur-
vival exceeds 12 months.
The STS recommends against
routine predischarge echocardi-
ography after aortic valve re-
placement (58) and suggests tak-
ing baseline echocardiographic
measurements of a prosthetic
valve at the first follow-up visit, 2
to 4 weeks after hospital dis-
charge. At that time, ventricular
function has had the opportunity
to recover, and anemia and the
resulting hyperdynamic hemody-
namic state have improved.
Annals of Internal Medicine 3 January 2017
 In the Clinic Patient Information
www.mayoclinic.org/diseases-conditions/aortic

Tool Kit
-stenosis/basics/definition/con-20026329
Information on aortic stenosis from the Mayo Clinic for
both patients and medical professionals.
www.heart.org/HEARTORG/Conditions/More/Heart-
ValveProblemsandDisease/Problem-Aortic-Valve
-Stenosis_UCM_450437_Article.jsp#.WCXe2y0rLow

Aortic Stenosis Detailed information from the American Heart Associa-

IntheClinic
tion for both patients and health care professionals;
page contains multimedia content links.
http://patient.info/health/aortic-stenosis-leaflet
Information on aortic stenosis, including diagrams of the
heart, to let patients see what the condition involves.
Web site contains information about causes, symptoms,
and possible complications.
http://es.heart.org/dheart/HEARTORG/Conditions
/Answers-by-Heart-Fact-Sheets-Multi-language
-Information_UCM_314158_Article.jsp#.WCX1Oi0rLow
American Heart Association information for patients, in
Spanish.
http://umm.edu/health/medical/spanishency/articles
/estenosis-aortica
University of Maryland Medical Center information for
patients, in Spanish.
Clinical Guidelines
http://content.onlinejacc.org/article.aspx?
articleid=1838843
Joint guideline from the American College of Cardiology
and the American Heart Association on the manage-
ment of patients with heart valve disease.
www.escardio.org/Guidelines/Clinical-Practice
-Guidelines/Valvular-Heart-Disease-Management-of
European Society of Cardiology's guideline on heart valve
disease.

3 January 2017 Annals of Internal Medicine ITC15 姝 2017 American College of Physicians

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 WHAT YOU SHOULD KNOW In the Clinic
Annals of Internal Medicine
ABOUT AORTIC STENOSIS
What Is Aortic Stenosis?
Blood travels from the heart through the aortic
valve to the rest of your body. If you have aortic
stenosis, the heart has trouble pumping blood
the way it normally does because the aortic
valve does not open fully. This makes it more
difficult for the heart to supply your body with
the blood it needs. There is no cure for aortic
stenosis, but it can be managed. If left un-
treated, it can lead to heart failure or death. Aor-
tic stenosis can be something that you are born
with or something that you develop. Factors that
may increase your risk include:
• Smoking
• High blood pressure
• High cholesterol • Using medication to maximize the heart's
• Older age ability to pump blood
• Family history • Replacing the damaged valve, either during
surgery or by using a catheter threaded into
What Are the Warning Signs? the heart through an artery
Symptoms may include:
• Chest pains with exercise or strong emotions Questions for My Doctor
• Trouble breathing • Am I at risk for aortic stenosis?
• Feeling faint or fainting • Do I need to change what I eat and drink?
Symptoms usually do not occur until aortic steno- • Should I worry about any of the medicines I'm
sis is advanced. Earlier stages can be recognized currently taking?
when a physical examination detects an abnor- • Can I still do all the things I like to do?
mal heart sound. • What kind of exercise can I do?
• Is surgery the right option for me?
How Is It Diagnosed? • When should I go to the emergency room?
• Your doctor will talk with you about any

symptoms you may have.
• He or she will also examine your heart using a
stethoscope to listen for any abnormal heart
sounds.
• In many cases, your doctor will also order a
test that uses sound waves to create a video of
your aortic valve in action.
How Is It Treated?
If you have aortic stenosis, you should have regu-
lar checkups with your doctor. The management
of aortic stenosis includes:
• Avoiding demanding sports and other hard
physical activity
Patient Information
Bottom Line
Aortic stenosis happens when the aortic valve in
your heart does not open fully. This makes it
harder for your heart to pump blood into your
body. Aortic stenosis can lead to heart failure or
death.
People with early aortic stenosis usually do not
have symptoms. Symptoms include chest pains,
trouble breathing, or feeling faint or fainting.
Aortic stenosis cannot be fixed with medicines, but
they can help relieve some symptoms. Once
symptoms develop, it usually is necessary to re-
place the aortic valve, but the patient and doctor
should work together to decide what is best.

For More Information

MedlinePlus
https://medlineplus.gov/ency/article/000178.htm
American Heart Association
www.heart.org/HEARTORG/Conditions/More/HeartValveProblem-
sandDisease/Problem-Aortic-Valve-Stenosis_UCM_450437_Article
.jsp#.WBeG_S0rKJA

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