OVERVIEW

What is aortic valve stenosis?

Aortic valve stenosis is a condition where the valve opening narrows, reducing blood flow through the valve. It can be caused by infection, rheumatic fever, degenerative changes with aging, or rare congenital abnormalities. Typically, the valve tissue becomes scarred, inflamed, or thickened. Calcium deposits may form on the valve, reducing the flexibility of the valve leaflets. Symptoms may include chest pain, fatigue, shortness of breath, dizziness, fainting, or difficulty exercising. However, it is important to note that heart valve diseases often present no external symptoms and can be difficult to detect.

How common is aortic valve stenosis?

The incidence of aortic valve stenosis increases with age. It affects only about 0.2% of people aged 50–59, while the prevalence rises to 9.8% in those aged 80–90. The overall incidence in individuals over 75 is 2.8%.

What are the types of aortic valve stenosis?

It can be classified based on clinical severity into the left ventricular compensatory phase and the left ventricular decompensatory phase.

SYMPTOMS

Clinical Manifestations of Left Ventricular Compensation Period?

Mild to moderate aortic stenosis may remain asymptomatic for many years. Patients with this condition can experience sudden death without obvious symptoms.

Clinical Manifestations of Left Ventricular Decompensation Period?

Characteristic symptoms of severe aortic stenosis include dyspnea, angina, and syncope.

• Dyspnea: Exertional dyspnea is the most common initial symptom caused by late-stage pulmonary congestion, occurring in 90% of symptomatic patients. This may progress to paroxysmal nocturnal dyspnea, orthopnea, and acute pulmonary edema.
  
  
• Angina: Occurs in 60% of symptomatic patients. The mechanism may involve increased oxygen demand due to myocardial hypertrophy and relative reduction in coronary blood flow, leading to subendocardial ischemia. It is often triggered by exertion and relieved by rest.
  
  
• Syncope: Often manifests as transient visual blackout or brief loss of consciousness after exertion or sudden postural changes. Severe arrhythmias (e.g., sustained ventricular tachycardia, high-grade AV block, or severe sinus bradycardia) due to myocardial ischemia may also cause syncope or sudden death. Average survival is 2-5 years after onset of syncope or angina.

Consequences of Aortic Stenosis?

While asymptomatic aortic stenosis does not increase mortality, the mortality rate exceeds 50% within 2 years after symptom onset unless aortic valve replacement is performed immediately.

CAUSES

What are the common causes of aortic stenosis?

• Congenital bicuspid valve deformity is the most common congenital cause of aortic valve stenosis, occurring more frequently in males than females and affecting approximately 1%–2% of the population.
  
  
• Rheumatic inflammation can also lead to fibrosis, stiffness, and calcification at the valve commissures, resulting in valve orifice stenosis.
  
  
• Degenerative senile calcific aortic stenosis: The most common cause of isolated aortic stenosis in the elderly over 65 years old, often accompanied by mitral annular calcification.

Who is prone to aortic valve stenosis?

High-risk groups for aortic valve stenosis include individuals with a history of mediastinal radiation, kidney failure, familial hypercholesterolemia, or calcium metabolism disorders. Adolescents with a history of rheumatic fever and degenerative senile calcific aortic stenosis are also relatively common. Additionally, males are generally more affected than females.

Under what circumstances is aortic valve stenosis more likely to occur?

For those prone to aortic valve stenosis, triggers may include exposure to cold, colds, various infections, fatigue or poor rest, anger or emotional agitation, sudden discontinuation of medication, or excessive fluid infusion.

DIAGNOSIS

Suspected aortic valve stenosis, what tests are needed?

X-ray; Electrocardiogram (ECG); Echocardiography and left heart catheterization.

Why are these tests necessary? What are their purposes?

• X-ray: Determines whether the heart shadow is normal or enlarged. Lateral fluoroscopy can also detect calcification of the aortic valve.
• Electrocardiogram (ECG): In severe stenosis, left ventricular hypertrophy with secondary ST-T changes and left atrial enlargement may be observed. Severe aortic valve calcification can lead to atrioventricular or intraventricular block.
• Echocardiography: Two-dimensional echocardiography is highly sensitive in detecting aortic valve abnormalities, helping visualize valve structure (e.g., number of leaflets, size, thickening, calcification, systolic doming, commissural fusion, orifice size/shape, and annulus size). It aids in identifying the cause of stenosis but cannot precisely quantify its severity.
• Left heart catheterization: Performed when echocardiography cannot definitively assess stenosis severity and valve replacement is considered. This test directly measures pressures in the left atrium, left ventricle, and aorta.

What precautions should be taken during testing?

Patients with severe aortic stenosis may postpone testing until symptoms alleviate. If immediate testing is required, bedside chest X-rays or echocardiography can be performed.

Which conditions is aortic valve stenosis easily confused with?

Aortic stenosis should be differentiated from holosystolic murmurs of mitral regurgitation, tricuspid regurgitation, or ventricular septal defects. Additionally, it must be distinguished from other left ventricular outflow tract obstruction diseases.

TREATMENT

Which department should I visit for aortic valve stenosis?

Cardiology, Emergency Department, Cardiac Surgery.

How to self-rescue in case of aortic valve stenosis?

If a patient with aortic valve stenosis experiences angina symptoms, they should take nitroglycerin sublingually and call 120 after symptoms ease. If the patient has difficulty breathing, stay calm first and ask others to call 120.

How to provide first aid if a family member has aortic valve stenosis?

Stay calm and avoid panic. Help the patient into a semi-recumbent position or sit up slowly. If accompanied by angina, immediately administer nitroglycerin sublingually and call 120, accurately describing the patient's condition. Avoid strenuous physical activities for the patient in daily life.

How is aortic valve stenosis treated?

• Medical treatment:
  • Rheumatic aortic valve stenosis requires anti-rheumatic therapy;
  • Prevent infective endocarditis;
  • Asymptomatic patients with mild stenosis should undergo re-examination every 2 years, including quantitative echocardiography.
  • Patients with moderate or severe stenosis should avoid strenuous physical activity and be re-examined every 6–12 months. Frequent atrial premature contractions should be treated with antiarrhythmic drugs to prevent atrial fibrillation.
  • Other arrhythmias causing symptoms or hemodynamic consequences should also be actively treated. Nitrates may be tried for angina. Patients with heart failure should limit sodium intake and may use digitalis and diuretics cautiously.
• Surgical treatment: Artificial valve replacement is the primary method for treating adult aortic stenosis.
  • Asymptomatic patients with mild or moderate stenosis do not require surgery.
  • Severe stenosis (valve area < 0.75 cm² or mean transvalvular pressure gradient > 50 mmHg) with angina, syncope, or heart failure symptoms is the main indication for surgery.

• Percutaneous balloon aortic valvuloplasty: Mainly used for elderly patients, those with heart failure, or high surgical risk.

What types of drugs are used to treat aortic stenosis?

• Vasoactive drugs: Dopamine, nitroglycerin.
• Hormonal drugs: Dexamethasone, etc.
• Anti-infective drugs: Vancomycin.
• Cardiotonic drugs: Digoxin.
• Diuretics: Furosemide.

Is continued medication necessary after aortic stenosis improves?

Depending on the patient's condition, continued medication may be required, especially for patients with aortic stenosis-related loss of consciousness, blackouts, orthopnea, exertional dyspnea, or myocardial hypertrophy, who need lifelong medication.

What should be noted during hospitalization for aortic stenosis?

Cooperate with the doctor and nurse's treatment plan. Avoid strenuous physical activity.

Is follow-up necessary after discharge for aortic stenosis? How?

Asymptomatic patients with mild stenosis should undergo re-examination every 2 years, including quantitative echocardiography. Patients with moderate or severe stenosis should be re-examined every 6–12 months.

Can aortic stenosis be completely cured?

With active treatment, symptoms can be alleviated to varying degrees, but a complete cure is impossible. Some patients may remain asymptomatic for years, but most experience progressive worsening of stenosis.

Can aortic stenosis recur?

Most patients experience progressive worsening of stenosis. Once symptoms appear, prognosis deteriorates, with an average life expectancy of only about 3 years after symptom onset.

DIET & LIFESTYLE

What should patients with aortic stenosis pay attention to in their diet?

• Avoid high-fat and high-salt diets;
• Do not drink excessive water, as it increases the burden on the heart.
• Avoid stimulating foods and excitatory drugs, such as caffeine, which may trigger arrhythmias.

What should patients with aortic stenosis pay attention to in daily life?

• Strictly follow the doctor's instructions, take medications on time and in the prescribed dosage, and do not stop them without permission;
• Schedule regular follow-ups to monitor the condition and potential side effects of medications;
• Patients should learn about aortic stenosis to recognize worsening symptoms and seek immediate medical attention;
• Avoid various triggers, such as infective endocarditis.

Can patients with aortic stenosis exercise?

They can engage in moderate and gentle exercise but should avoid strenuous physical activities.

How to care for a family member with aortic stenosis?

• Encourage the patient to take medications regularly.
• If the patient experiences symptoms such as difficulty breathing, angina, or fainting, seek immediate medical help.

PREVENTION

How to Prevent Aortic Stenosis?

• Primary prevention refers to preventing the initial onset of rheumatic fever, with the key being early diagnosis and treatment of streptococcal pharyngitis. Anyone with symptoms such as fever, sore throat or discomfort, headache, abdominal pain, pharyngeal congestion, or tonsillar exudate should undergo a throat swab culture before treatment to confirm the presence of streptococcal infection. If positive, antibiotic therapy should be initiated immediately. Penicillin is the first-line treatment for all patients except those allergic to it.
  
  
• Secondary prevention (prevention of rheumatic fever recurrence) involves continuous antibiotic therapy for individuals with a confirmed history of rheumatic fever or existing rheumatic heart disease to prevent recurrence. The duration of prevention depends on the risk of recurrence. Generally, those with frequent upper respiratory infections, living in crowded conditions, poor medical access, or a history of multiple episodes are at higher risk and should receive prolonged preventive medication. Conversely, the duration may be shortened appropriately.
  
  
  • Patients with a history of rheumatic carditis have a relatively higher risk of recurrence and should receive long-term antibiotic prophylaxis, potentially lifelong or until adulthood.
    
    
  • In contrast, patients without a history of rheumatic carditis have a lower risk of cardiac involvement upon recurrence, and antibiotic prophylaxis can be discontinued after several years. Typically, prevention should continue until the patient reaches their twenties or for at least 5 years after the last episode of rheumatic fever.