How does aortic stenosis
affect the aortic valve?
A patient with aortic stenosis will experience calcification, lipid deposition, and inflammatory
infiltration of the aortic valve leaflets. Over time, these leaflets become increasingly stiff, leading to a
narrowing of the heart valve opening, obstructing blood flow and forcing the heart to pump harder.2
The severity of aortic stenosis is determined
by the calcification of the aortic valve leaflets:
-
Normal
-
Mild
-
Moderate
-
Severe
Timely intervention is key
In some patients, symptoms can manifest at a stage considered moderate, while other patients with severe AS may remain asymptomatic. However, once symptoms become apparent in patients with severe AS, life expectancy is greatly reduced. Left untreated, these patients have a survival rate as low as 50% at 2 years.3
How common is aortic stenosis?
In order to understand the prevalence of the disease,
please enter an estimate of the number of patients over 75 you see per week:
Elderly patients you see per year who might suffer from AS4
Patients who might have moderate or severe AS5
Patients who might not survive past 2 years if severe AS left untreated6
It is likely that these numbers will only increase as
populations continue to age. How many patients
have you suspected of aortic stenosis?
Why are patients being missed?
Many symptoms of aortic stenosis develop gradually and a patient will often adapt their lifestyle
to manage them, or simply blame them on 'old age.'7
Chest pain or tightness
Reduced physical activity
Palpitations
Shortness of breath
Fatigue
Feeling faint orfainting upon exertion
Public awareness of aortic stenosis is extremely low.
94% of the over 60s
in the UK do not know
what aortic stenosis is.8
This is why your role, as a primary care physician,
is so important in optimally diagnosing these patients.
Once symptoms appear in patients with severe AS, life expectancy
is severely reduced.3
Aortic stenosis can be latent in patients for a number of years, but once symptoms manifest life expectancy is significantly reduced.9
How you can help these patients?
A clear sign of aortic stenosis is a heart murmur.10
Indeed, most patients with aortic stenosis are first diagnosed following auscultation.12
The ideal position of the stethoscope can be seen in this graphic.
Usually heard best at the right sternal border, 2nd intercostal space. Often radiates to both carotid arteries.
Once positioned correctly, an audible systolic heart murmur suggests an aortic stenosis diagnosis.
Listen.
The murmur typically associated with aortic stenosis is a harsh systolic
ejection murmur, with a single or paradoxically split second heart sound.
Listen below to compare this to a normal heartbeat.
stenosis
Sound recording courtesy of Thinklabs. Recorded on a Thinklabs stethoscope.
If you suspect a heart murmur, refer.
To support optimal patient outcomes, patients with a clinical suspicion of aortic valve disease should be referred to a specialist (irrespective of symptoms) for further evaluation in order to aid in planning of appropriate long-term management11. The only effective treatment for severe aortic stenosis is to replace the diseased aortic valve.10 Medical therapy may provide temporary relief of symptoms, but does not improve outcomes.10 Balloon valvuloplasty may be considered as a bridge to valve replacement, but is usually followed by restenosis and deterioration within 6–12 months.10
Aortic valve replacement is regarded as the definitive therapy for severe aortic stenosis.10 The multi-disciplinary heart team will conduct a thorough evaluation of the patient’s status and make the final treatment decision for either surgical AVR (sAVR), or transcatheter aortic valve implantation (TAVI), a less-invasive treatment compared to surgery. This decision will be made based on patient risk for surgery and suitability.
If a heart murmur is suspected, refer to a specialist for further evaluation.
Resources
To support you in your practice a number of aortic stenosis educational materials have been developed, including materials to support patient consultation. All resources can be posted directly to your practice and are provided at no charge.
Patient Leave Piece – Card
Informs patients about the progression of aortic stenosis, the need to take action and the patient website where more information about the disease and treatment options are available.
Tips for Caregivers
Tips to help carers in supporting their loved one throughout their aortic stenosis journey.
Heart Anatomy Guide for Patient Consultation
Designed to support conversations with patients that have suspected heart valve disease. Enables simple explanation of the heart and its valves.
Patient Poster for Waiting Room – Recognizing Symptoms
Waiting room poster designed to support patients with heart valve disease symptom recognition, and request to discuss symptoms with their doctor.
Patient Brochure – Aortic Stenosis
Brochure for patients who have been diagnosed with aortic stenosis. Provides understanding of the disease and reassurance about treatment options.
Aortic Stenosis Brochure for Professionals
Brochure for primary care physicians, containing a brief summary of aortic stenosis prevalence, diagnosis, treatment options and current data.
Patient Brochure – Heart Valve Disease
Brochure for patients with a suspected heart murmur. Supports in their understanding of heart valve disease and referral pathway.
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External Resources
Exploring Aortic Stenosis: a primary and secondary care perspective
Listen to this conversation between a Cardiologist and a GP about the patient pathway of AS patients. In the beginning, the cardiologist asks the GP about the suspicion of AS in primary care, checks, and subsequent steps. Then, the conversation switches to the GP asking the cardiologist about the handling of patients referred with a suspicion of AS and the decision on their treatment options.
Speakers: Dr. Chris Young (Cardiac surgeon, St Thomas’ Hospital, London) and Dr. Chris Arden (GP, Chandlers Ford, Hampshire)
Accredited podcast with 0.5 educational points.
Listen, Suspect, Refer: A guide to detecting heart valve disease
Interactive eLearning module in partnership with the Royal College of General Practitioners and Dr Yassir Javaid, aiming to equip primary care physicians with the skills to detect and refer patients with valvular heart disease.
Duration: 30 minutes
Accredited module with 0.5 educational points.
Listen.
Suspect.
Refer.
If you think a colleague would benefit from this resource, please share to spread awareness.
1st interactive heart valve learning tool for GPs!
Heart Valve Master is the 1st UK educational tool to help GPs master their auscultation skills and detection of HVD through gamification.
References
- Bouma BJ, van den Brink RBA, van der Meulen JHP et al. To operate or not on elderly patients with aortic stenosis: the decision and its consequences. Heart 1999 Aug; 82: 143–8.
- Grimard BH, Larson JM. Aortic Stenosis: diagnosis and treatment. Am Fam Physician 2008;78:717–24
- Otto CM. Timing of aortic valve surgery. Heart 2000;84:211–218
- Based on a 48 week working year. Number calculated from pooled prevalence of all AS in the elderly (12.4%). Ref: Osnabrugge RLJ, Mylotte D, Head SJ et al. Aortic stenosis in the elderly: disease prevalence and number of candidates for transcatheter aortic valve replacement: a meta-analysis and modeling Study. J Am Coll Cardiol. 2013;62:1002–
- Osnabrugge RLJ, Mylotte D, Head SJ et al. Aortic stenosis in the elderly: disease prevalence and number of candidates for transcatheter aortic valve replacement: a meta-analysis and modeling Study. J Am Coll Cardiol. 2013;62:1002–12.
- Otto CM. Timing of aortic valve surgery. Heart 2000; 84:211-–218
- Alliance for Aging Research. Aortic Stenosis: Under-Diagnosed and Under-Treated. 2010. https://www.agingresearch.or/newsletters/view/36. Accessed August 12, 2016
- Gaede L, Di Bartolomeo R, van der Kley F et al. Aortic valve stenosis – what do people know? A Heart Valve Disease Awareness Survey of over 8,800 people aged 60 or over. Eurointervention: Journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology. 2016;12:883–9.
- Carabello BA. Introduction to aortic stenosis. Circ Res 2013;113:179–85
- Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC); European Association for Cardio-Thoracic Surgery (EACTS), Baumgartner H, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease (version 2017). Eur Heart J 2017;38:2739–91
- Dr Wern Yew Ding, Dr Unni Krishnan. Aortic Valve disease: Clinical Review. GP Online. 2016. http://www.gponline.com/aortic-valve-disease-clinical-review/cardiovascular-system/article/990063 . Accessed March 13th, 2017.
- Nishimura RA, Otto CM, Bonow RO et al. 2014 AHA/ACC Guideline for the management of patients with valvular heart disease: Executive summary. Circulation 2014; 10;129:2440–92.
