Intended for healthcare professionals

Practice Easily Missed?

Aortic stenosis

BMJ 2023; 380 doi: (Published 15 March 2023) Cite this as: BMJ 2023;380:e070511
  1. Harriet Hurrell, cardiology speciality trainee1,
  2. Michael Redwood, general practitioner2,
  3. Tiffany Patterson, consultant cardiologist1,
  4. Christopher Allen, BHF clinical research fellow1
  1. 1Department of Cardiology, St Thomas’ Hospital, London SE1 7EH, UK
  2. 2Bourn Surgery, Bourn, Cambridge CB23 2SH, UK
  1. Correspondence to: H Hurrell h.e.l.hurrell{at}

What you need to know

  • Auscultate for a systolic murmur (it can be soft) when patients present with chest pain, breathlessness, presyncope, syncope, palpitations, or unexplained functional deterioration

  • Clinically relevant aortic stenosis is underdiagnosed—consider transthoracic echocardiography and specialist assessment if there are cardiac or respiratory symptoms associated with an audible murmur

  • Arrange urgent cardiology assessment (within 2 weeks) or acute admission for syncope and/or rapidly deteriorating symptoms in suspected aortic stenosis

  • Transcatheter procedures are suitable for many patients who might previously have been deemed unfit for open valve replacement surgery

A woman in her 80s presents with progressive reduction in her exercise tolerance. Twelve months earlier, she could comfortably complete a round of golf on foot; now she needs to stop and catch her breath after walking 100 yards. A soft systolic murmur is heard on auscultation, and blood tests show a mild microcytic anaemia. As the murmur is quiet, it is assumed the anaemia is causing her symptoms, and oral iron is prescribed. Over the next 12 months, she develops progressive breathlessness on exertion but respiratory causes are excluded. Six months later she has an episode of syncope while shopping. A quiet second heart sound is noted.

What is aortic stenosis?

Aortic stenosis is narrowing of the aortic valve (fig 1). The resulting obstructed blood flow from the left ventricle to the aorta causes increased left ventricular afterload, compensatory left ventricular hypertrophy, reduced compliance, and impaired diastolic function.12 Severe disease carries a poor prognosis,345 yet many patients remain undiagnosed.67

Fig 1

Appearances of healthy and stenotic tricuspid aortic valves

Symptoms are usually associated with severe disease and are non-specific, including ischaemic chest pain (reported in up to 63% of patients), exertional dyspnoea (53-77%), fatigue (8%), and presyncope or syncope (2%).3891011 Patients might also initially present with acute heart …

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