PassFinals
Cardiovascular

Aortic Stenosis

Progressive narrowing of the aortic valve creates left-ventricular pressure overload; symptomatic severe disease needs specialist valve-team assessment for intervention.

In a nutshell

Aortic stenosis is an outflow obstruction. Think exertional dyspnoea, angina and syncope; confirm with integrated echocardiography; symptomatic severe disease needs valve intervention.

Classic presentation

Older adult with exertional breathlessness, angina or syncope and a harsh ejection systolic murmur radiating to the carotids.

Key points

  • Echocardiography confirms and grades stenosis; do not diagnose severity from murmur intensity alone.
  • Symptoms may be subtle: ask about exercise reduction and functional change.
  • Urgent echo is needed for a murmur with exertional syncope or severe symptoms.
  • Offer intervention for symptomatic severe disease; consider intervention in selected asymptomatic severe disease using NICE triggers.
  • Surgical replacement is first line for suitable low/intermediate-risk patients; TAVI is a specialist heart-team decision.
  • Low-flow low-gradient disease needs integrated imaging and sometimes dobutamine stress echocardiography.

First-line investigation

Transthoracic echocardiography with integrated assessment of valve, flow, gradient, ventricular function and aorta.

Management

Recognise red flags

  • Exertional syncope or severe symptoms with a murmur needs urgent assessment; pulmonary oedema, shock or refractory chest pain is an emergency.1

Confirm severity

  • Use TTE and integrate velocity, gradient, valve area, flow, ventricular function and symptoms.1,2

Refer symptomatic severe disease

  • Offer intervention for symptomatic severe AS after multidisciplinary valve-team assessment.1

Resolve discordant or asymptomatic disease

  • Consider exercise testing, CT calcium scoring or dobutamine stress echo in selected patients and apply the NICE asymptomatic triggers.1

Surveil and reassess

  • Use severity- and symptom-based surveillance; new symptoms should trigger urgent reassessment.1,2

Exam traps

  • A soft murmur does not exclude severe low-flow disease, and a loud murmur does not establish severity.
  • Syncope on exertion is a red flag, not benign vasovagal syncope until assessed.
  • Do not use a single valve-area or gradient value without considering flow and ventricular function.
  • Do not promise TAVI solely from age or a risk score; the valve team assesses anatomy, prognosis, preferences and risk.

Illustrations

Concentric hypertrophy from pressure overloadDiagram illustrating Laplace's law, showing how a pressure-overloaded ventricle thickens its walls in parallel to normalise wall stress.PassFinals · original
Auscultation findings in aortic stenosisIllustration of the ejection systolic murmur radiating to the carotids alongside the slow-rising carotid pulse waveform.PassFinals · original
Gross pathology of a stenotic aortic valveGross specimen showing thickened, fused rheumatic aortic valve cusps leaving a markedly narrowed central orifice.CDC/Dr. Edwin P. Ewing, Jr, Wikimedia Commons · Public domain

Key sources

  1. NICE NG208: Heart valve disease presenting in adults (Referral, investigation, pharmacological management, intervention and follow-up recommendations)Published 17 Nov 2021 | Updated 24 Oct 2025
  2. BSE/BHVS: Clinical indications and triage for echocardiography in heart valve disease (UK consensus on referral, red flags and surveillance)Published 1 Aug 2024
  3. NICE HTG757: Transcatheter aortic valve implantation for aortic stenosis (Valve technology, governance and registry recommendations)Published 25 Jun 2025
  4. NICE NG208: Heart valve disease presenting in adults — overview (Current guideline status and update information)Published 17 Nov 2021 | Updated 24 Oct 2025

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.