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Practice Clinical updates

Aortic stenosis: diagnosis and management

BMJ 2016; 355 doi: (Published 19 October 2016) Cite this as: BMJ 2016;355:i5425
  1. M Zakkar, NIHR academic clinical lecturer and honorary cardiac surgery registrar,
  2. A J Bryan, consultant cardiac surgeon,
  3. G D Angelini, British Heart Foundation professor of cardiac surgery
  1. Bristol Heart Institute, Bristol Royal Infirmary, Bristol BS2 8HW, UK
  1. Correspondence to: M Zakkar m.zakkar{at}

What you need to know

  • Aortic stenosis is a slowly progressive disease

  • Patients are initially asymptomatic with an incidental finding of crescendo-decrescendo heart murmur

  • After the onset of symptoms, there is a marked reduction in survival

  • The two options for valve intervention are conventional aortic valve replacement (AVR) or transcatheter aortic valve implantation (TAVI)

  • Patients with mechanical valves require lifelong anticoagulation

The overall prevalence of clinically significant aortic stenosis in patients >70 years old in Europe is approximately 1-3%, making it the most common valvular heart diseases in developed countries.1 2 3 4 Aortic stenosis is a narrowing of the aortic valve that results in restricted blood flow to the body and eventually compromised heart function. Aortic sclerosis is the thickening and calcification of aortic leaflets without motion restriction (fig 1). Aortic sclerosis affects one in four of patients >65 years old in developed countries.

Fig 1 Anatomy and function of the aortic valve. The valve controls blood flow from the heart by allowing unobstructed forward flow during systole and preventing blood return to the heart during diastole. It is made of three leaflets in most patients. In aortic stenosis, calcific degeneration of the aortic leaflets reduces opening and prevents full closure

This review describes the causes, pathophysiology, presentation, and treatment of aortic stenosis.1 2 3 4

Who gets aortic stenosis?

Calcific degeneration of aortic leaflets is the most common cause of aortic stenosis in patients >70 years old in developed countries. The leading cause of aortic stenosis in younger patients is bicuspid aortic valve. This is a congenital abnormality in which the valve is made of two leaflets rather than the normal three leaflet configuration and occurs in 1-2% of the general population in developed countries. Other causes are listed in box 1.2 3 5

Box 1: Causes of aortic stenosis

  • Calcific degeneration

  • Bicuspid aortic valve

  • Rheumatic fever

Degenerative changes …

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