Elsevier

The Lancet

Volume 373, Issue 9667, 14–20 March 2009, Pages 956-966
The Lancet

Review
Aortic stenosis

https://doi.org/10.1016/S0140-6736(09)60211-7Get rights and content

Summary

In developed countries, aortic stenosis is the most prevalent of all valvular heart diseases. A manifestation of ageing, the disorder is becoming more frequent as the average age of the population increases. Symptomatic severe disease is universally fatal if left untreated yet is consistent with a typical lifespan when mechanical relief of the stenosis is provided in a timely fashion. Management of mild disease, severe asymptomatic disease, and far advanced disease, and the effect of new percutaneous treatments, provide both controversy and exciting promise to care of patients with aortic stenosis. We discuss these issues in this Review.

Section snippets

Epidemiology

Aortic valvular abnormalities are quite frequent in old patients. In the Cardiovascular Health Study, in which 5201 men and women older than 65 years were examined, 26% of study participants had aortic sclerosis (a thickening of the valve or calcification without significant obstruction). A slight predominance of the disorder was noted in men. 2% of all patients had frank aortic stenosis.1 A clear increase in prevalence of sclerosis was seen with age: 20% in patients aged 65–75 years, 35% in

Calcific aortic stenosis

Once judged a degenerative disease, the mechanism by which a previously healthy tricuspid aortic valve becomes stenotic is now believed to be very similar to that of atherosclerosis. The initial plaque of aortic stenosis is alike that of coronary artery disease.2 Risk factors associated with coronary artery disease—including age, male sex, hyperlipidaemia, and evidence of active inflammation—are held in common by the two disorders.3 Further, there is a high coincidence of both diseases in the

Pathophysiology and relation to symptoms

Onset of severe symptoms of aortic stenosis—angina, syncope, and heart failure—remains the major demarcation point in the disease's course (figure 1).19 The asymptomatic patient has a good outlook even with severe obstruction, whereas an individual with symptoms has a mortality rate of about 25% per year. Thus, knowing how the pathophysiology of aortic stenosis causes symptoms and death is paramount to understanding the disease.

Physical examination

Aortic stenosis is usually detected initially by auscultation that indicates the typical crescendo-decrescendo systolic ejection murmur radiating to the neck. In mild disease, the murmur peaks early in systole, S2 is physiologically split, and carotid upstrokes are normal. This condition—in which a thickened valve causes no appreciable obstruction to outflow—is termed aortic sclerosis. Although by itself benign, presence of aortic sclerosis is associated with a substantial increase in risk for

Medical treatment

Severe symptomatic aortic stenosis is a lethal obstruction to outflow that needs effective mechanical relief in the form of valve replacement for most patients. No medical treatment is effective for chronic disease. However, as noted above (see section on Causes), modern ideas about valve pathology (rather than the effects of stenosis on the heart and body) indicate that aortic stenosis is caused by an active inflammatory process akin to that of atherosclerosis.60, 61 Thus unsurprisingly,

Conclusions and future work

Symptomatic severe aortic stenosis is a fatal disease when treated medically, but after aortic valve replacement a patient's lifespan returns to near that of an unselected population.94 Even individuals with advanced disease and left-ventricular dysfunction can have a good outcome, especially when the reason for the dysfunction is a large transvalvular gradient causing high afterload. In people with aortic stenosis and a low gradient and low ejection fraction, prognosis is worse but is still

Search strategy and selection criteria

We searched PubMed with the keyword “aortic stenosis”. We identified citations that formed a mix of important older studies and those published since 2000. Citations from journals with high impact factors were given special weight, and we attempted to balance sources from the USA and Europe.

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