Aortic stenosis is the most common type of heart valve disease in the elderly.1

Symptomatic patients have a greatly reduced
life expectancy if left untreated.1

As a primary care physician you play a vital role in diagnosis,
and ensuring patients receive appropriate treatment.

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

Prevalence

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:

8 8 327 Down arrow
8 8 8 327

Elderly patients you see per year with aortic stenosis4

8 8 8 90

Patients who have moderate or severe aortic stenosis4

8 8 8 45

Patients who won’t survive past 2 years if left untreated5

It is likely that these numbers will only increase as
populations continue to age. How many patients
have you suspected of aortic stenosis?

Symptoms

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.'6

Chest pain or tightness
Reduced physical activity
Palpitations
Shortness of breath
Fatigue
Feeling faint or
fainting upon exertion

Once symptoms appear in patients with severe AS, life expectancy
is severely reduced.3

graph
Figure adapted from 7

Aortic stenosis can be latent in patients for a number of years, but once symptoms manifest life expectancy is significantly reduced.7

Diagnosis

How you can help these patients?

A clear sign of aortic stenosis is a heart murmur.8

Indeed, most patients with aortic stenosis are first diagnosed following auscultation.10
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.

Normal
Aortic
stenosis

Sound recording courtesy of Thinklabs. Recorded on a Thinklabs stethoscope.

Treatment

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 cardiologist (irrespective of symptoms) to aid in planning of appropriate long-term management9. The only effective treatment for severe aortic stenosis is to replace the diseased aortic valve.8 Medical therapy may provide temporary relief of symptoms, but does not improve outcomes.8 Balloon valvuloplasty may be considered as a bridge to valve replacement, but is usually followed by restenosis and deterioration within 6–12 months.8

Aortic valve replacement is regarded as the definitive therapy for severe aortic stenosis.8 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 cardiologist immediately.

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.

https://listentotheirheart.com.au/wp-content/uploads/media/E6545_CG_Brochure.jpg

Aortic Stenosis an Overview

Brochure for primary care physicians, containing a details on Clinical evaluation, Guidelines and Treatment: from Surgery to Current Indications for TAVI

ANZTHV-2018-12
Available formats:
Order
https://listentotheirheart.com.au/wp-content/uploads/media/E6646_AS_Patient_Brochure-01.jpg

Patient Brochure - What is Aortic Stenosis

Brochure for patients who have been diagnosed with aortic stenosis. Provides understanding of the disease and reassurance about treatment options.

ANZTHV-2017-27
Available formats:
Order
https://listentotheirheart.com.au/wp-content/uploads/media/E6584_AS-Brochure-for-GPs_final-01.jpg

Aortic Stenosis Brochure for Professionals

Brochure for primary care physicians, containing a brief summary of aortic stenosis prevalence, diagnosis, treatment options and current data.

ANZTHV-2018-08
Available formats:
Order
https://listentotheirheart.com.au/wp-content/uploads/media/E6645_HVD_Patient_Brochure-1.jpg

Patient Brochure - Have you been told you have a Heart Murmur

Brochure for patients with a suspected heart murmur. Supports in their understanding of heart valve disease and referral pathway.

ANZTHV-2018-09
Available formats:
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Listen.
Suspect.
Refer.

If you think a colleague would benefit from this resource, please share to spread awareness.

References

  1. 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.
  2. Grimard BH, Larson JM. Aortic Stenosis: diagnosis and treatment. Am Fam Physician 2008;78:717–24
  3. Otto CM. Timing of aortic valve surgery. Heart 2000;84:211–218
  4. 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.
  5. Otto CM. Timing of aortic valve surgery. Heart 2000; 84:211–218
  6. Alliance for Aging Research. Aortic Stenosis: Under-Diagnosed and Under-Treated. 2010. https://www.agingresearch.or/newsletters/view/36. Accessed August 12, 2016
  7. Carabello BA. Introduction to aortic stenosis. Circ Res 2013;113:179–85
  8. Vahanian et al. Guidelines on the management of valvular heart disease (version 2012). Eur. Heart J. 2012;33:2451–2496
  9. 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.
  10. 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.