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Aortic stenosis
Aortic stenosis progresses silently for years, but once symptoms appear — angina, exertional syncope or breathlessness — the prognosis is poor and the valve must be replaced.
Why it matters in the exam
The exam tests the physical examination (an ejection murmur heard best at the second right intercostal space and carried to the neck vessels, a small and late pulse — parvus et tardus, a soft second sound, sometimes paradoxical splitting, a fourth sound), the echocardiographic definition of severe stenosis, and the decision to intervene. In severe stenosis the murmur peaks later, and loudness alone is a poor guide to severity.
Candidates are also asked about the choice between transcatheter replacement (TAVI) and surgery, low-flow low-gradient states that need a dobutamine stress echocardiogram, the link with gastrointestinal bleeding (angiodysplasia with acquired von Willebrand deficiency), and caution with vasodilators and nitrates. The usual cause in the elderly is degenerative calcification, and in younger patients a bicuspid valve.
A classic question presents an older patient who fainted on exertion, with a systolic murmur and a weak carotid pulse, and asks for the next test — an echocardiogram — and the treatment when the stenosis is severe. Remember that the decision is made by a heart team of cardiologist and surgeon, and that significant coronary disease is treated together with the valve.
Key points
- Severe stenosis: velocity 4 m/s or more, mean gradient 40 mmHg or more, area below 1.0 cm².
- Classic symptoms: angina, exertional syncope and breathlessness.
- Symptomatic severe stenosis = valve replacement.
- Without symptoms — intervene if EF is below 50% or the exercise test is abnormal.
- TAVI at 75 or older or at high surgical risk; surgery in younger, low-risk patients.
Summary table
| Parameter | Severe stenosis | Meaning | Exam note |
|---|---|---|---|
| Peak velocity | 4 m/s or more | Severe stenosis | Doppler echocardiography |
| Mean gradient | 40 mmHg or more | Severe stenosis | With low flow the gradient may be low despite severe stenosis |
| Valve area | Below 1.0 cm² | Severe stenosis | Indexed: below 0.6 cm²/m² |
| Indication to intervene | Severe stenosis with symptoms | Valve replacement | Also without symptoms: EF below 50% or an abnormal exercise test |
| Type of intervention | TAVI at 75 or older or at high surgical risk | Surgery in younger, low-risk patients | Heart-team decision |
A free exam question
A 78-year-old female patient, referred for evaluation of recently diagnosed syncope and heart murmur. After a careful physical examination, you conclude that the patient has severe aortic valve stenosis. Which of the following descriptions of murmurs best fits the patient's diagnosis?
- A. Prominent systolic murmur in the left second intercostal space, with a fixed splitting of S2
- B. A high grade 5/6 systolic murmur in the right second intercostal space, a small-volume carotid pulse that rises and falls slowly, paradoxical splitting of S2
- C. A high systolic murmur heard at the base of the heart that increases in intensity with the Valsalva Maneuver and a fast-rising, high-volume carotid pulse
- D. Grade 5/6 holosystolic murmur at the apex of the heart, radiating to the axilla
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Sources
- ESC/EACTS Guidelines for the management of valvular heart disease, 2021 — Aortic stenosis: evaluation and indications for intervention
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Aortic Valve Disease
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.