Aortic stenosis symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Mohammed A. Sbeih, M.D. [2]; Lakshmi Gopalakrishnan, M.B.B.S. [3]; Usama Talib, BSc, MD [4] Assistant Editor-In-Chief: Kristin Feeney, B.S. [5]

## Overview

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The main symptoms of aortic stenosis are angina, syncope, and congestive heart failure. Left untreated, the average survival is 5 years after the onset of angina, 3 years after the onset of syncope, and 1 year after the onset of congestive heart failure. Other symptoms of aortic stenosis are dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea.

## Symptoms

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### Symptoms by Age Group

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#### Symptoms in Adults

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The following symptoms are observed in adults with aortic stenosis.[1][2][3][4]

* Breathlessness with activity
* Chest pain, which resembles what is known as angina-type pain
* The pain is crushing, squeezing, pressure or tightness in nature
* The pain increases with exercise, relieved with rest
* The patient feels pain under the chest bone, it may move to other areas
* Fainting, weakness, or dizziness with activity
* Sensation of feeling the heart beat (palpitations)

#### Symptoms in Infants and Children

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The following symptoms were observed in infants and children with aortic stenosis.[5][6][7]

* Becoming tired or fatigued with exertion more easily than others (in mild cases)
* Serious breathing problems that develop within days or weeks of birth (in severe cases)
* Extreme fatigue
* Sweating
* Pale skin
* Fast breathing
* They may also be smaller than other children their age
* Children with mild or moderate aortic stenosis may get worse as they get older. They also run the risk of developing an infection of the heart valves (bacterial endocarditis).

### Angina Pectoris

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The following are a few important aspects about Angina Pectoris in Aortic Stenosis. [8] [9][10]

* The hypertrophied left ventricle and the prolonged ejection time (the time for the heart to eject blood) result in an increased myocardial oxygen requirements. The elevated diastolic filling pressure also reduces the gradient between the aorta and the right atrium ("the height of the waterfall") which normally drives coronary blood flow. The hypertrophied ventricle may also compress the capillaries. All of the above reasons lead to a reduction in coronary blood flow even in the absence of obstructive epicardial stenoses. This may result in subendocardial ischemia during stress or exercise.
* Left untreated, the average survival is 5 years after the onset of angina in the patient with aortic stenosis.

### Syncope

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The mechanism of syncope secondary to aortic stenosis remains unclear. Left untreated, the average survival is 3 years after the onset of syncope in the patient with aortic stenosis. Three theories have been hypothesized to explain the relationship between aortic stenosis and syncope:[11]

* Severe aortic stenosis results in a nearly fixed cardiac output. During exercise, the peripheral vascular resistance will decrease as the blood vessels dilate to allow the skeletal muscles to receive more blood. This decrease in peripheral vascular resistance is normally compensated by an increase in the cardiac output. Since patients with severe aortic stenosis cannot increase their cardiac output, the blood pressure falls and the patient will develop syncope due to decreased blood flow to the brain.

* During exercise, the high pressures generated in the hypertrophied left ventricle may cause a vasodepressor response, which subsequently results in peripheral vasodilation. As a consequence, the blood flow to the brain may decrease. Therefore, due to the fixed outwards blood flow obstruction at the level of the stenosed aortic valve, it may be impossible for the heart to increase its output to offset the peripheral vasodilation.

* Syncope can occur in patients with aortic stenosis secondary to myocardial ischemia. Myocardial ischemia can develop in patients with aortic stenosis due to the hypertrophy of the left ventricle and the subsequent inability of the coronary arteries to adequately supply blood to the myocardium.

### Congestive Heart Failure

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CHF in the setting of aortic stenosis is due to a combination of systolic dysfunction (a decrease in the ejection fraction) and diastolic dysfunction (elevated filling pressure of the left ventricle). Left untreated, the average survival is 5 years after the onset of angina, 3 years after the onset of syncope, and 1 year after the onset of congestive heart failure. [12][13][14]

Symptoms of left ventricular failure include the following:

* Dyspnea on exertion
* Fatigue
* Orthopnea
* Paroxysmal nocturnal dyspnea
* Pulmonary edema
* Pulmonary hypertension that can lead to:

* Right ventricular failure
* Hepatomegaly
* Atrial fibrillation
* Peripheral edema
* Tricuspid regurgitation

## References

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1. ↑ Rajani R, Rimington H, Chambers JB (2010). "Treadmill exercise in apparently asymptomatic patients with moderate or severe aortic stenosis: relationship between cardiac index and revealed symptoms". Heart. 96 (9): 689–95. doi:10.1136/hrt.2009.181644. PMID 20424150.CS1 maint: Multiple names: authors list (link)
2. ↑ Amato MC, Moffa PJ, Werner KE, Ramires JA (2001). "Treatment decision in asymptomatic aortic valve stenosis: role of exercise testing". Heart. 86 (4): 381–6. PMC 1729928. PMID 11559673.CS1 maint: Multiple names: authors list (link)
3. ↑ Das P, Pocock C, Chambers J (2000). "The patient with a systolic murmur: severe aortic stenosis may be missed during cardiovascular examination". QJM. 93 (10): 685–8. PMID 11029480.CS1 maint: Multiple names: authors list (link)
4. ↑ Park SJ, Enriquez-Sarano M, Chang SA, Choi JO, Lee SC, Park SW; et al. (2013). "Hemodynamic patterns for symptomatic presentations of severe aortic stenosis". JACC Cardiovasc Imaging. 6 (2): 137–46. doi:10.1016/j.jcmg.2012.10.013. PMID 23489526.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
5. ↑ Mody MR, Nadas AS, Bernhard WF (1967). "Aortic stenosis in infants". N Engl J Med. 276 (15): 832–8. doi:10.1056/NEJM196704132761503. PMID 6020739.CS1 maint: Multiple names: authors list (link)
6. ↑ ONGLEY PA, NADAS AS, PAUL MH, RUDOLPH AM, STARKEY GW (1958). "Aortic stenosis in infants and children". Pediatrics. 21 (2): 207–21. PMID 13505014.CS1 maint: Multiple names: authors list (link)
7. ↑ Yun SW (2011). "Congenital heart disease in the newborn requiring early intervention". Korean J Pediatr. 54 (5): 183–91. doi:10.3345/kjp.2011.54.5.183. PMC 3145901. PMID 21829408.
8. ↑ E. L. Fallen, W. C. Elliott & R. Gorlin (1967). "Mechanisms of angina in aortic stenosis". Circulation. 36 (4): 480–488. PMID 6041860. Unknown parameter `|month=` ignored (help)
9. ↑ Marcus ML, Doty DB, Hiratzka LF, Wright CB, Eastham CL (1982). "Decreased coronary reserve: a mechanism for angina pectoris in patients with aortic stenosis and normal coronary arteries". N Engl J Med. 307 (22): 1362–6. doi:10.1056/NEJM198211253072202. PMID 6215582.CS1 maint: Multiple names: authors list (link)
10. ↑ Carabello BA (2002). "Clinical practice. Aortic stenosis". N Engl J Med. 346 (9): 677–82. doi:10.1056/NEJMcp010846. PMID 11870246.
11. ↑ S. Frank, A. Johnson & J. Jr Ross (1973). "Natural history of valvular aortic stenosis". British heart journal. 35 (1): 41–46. PMID 4685905. Unknown parameter `|month=` ignored (help)
12. ↑ Ross J, Braunwald E (1968). "Aortic stenosis". Circulation. 38 (1 Suppl): 61–7. PMID 4894151.
13. ↑ Kelly TA, Rothbart RM, Cooper CM, Kaiser DL, Smucker ML, Gibson RS (1988). "Comparison of outcome of asymptomatic to symptomatic patients older than 20 years of age with valvular aortic stenosis". Am J Cardiol. 61 (1): 123–30. PMID 3337000.CS1 maint: Multiple names: authors list (link)
14. ↑ Iivanainen AM, Lindroos M, Tilvis R, Heikkilä J, Kupari M (1996). "Natural history of aortic valve stenosis of varying severity in the elderly". Am J Cardiol. 78 (1): 97–101. PMID 8712130.CS1 maint: Multiple names: authors list (link)

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