Diagnosis of aortic stenosis

Indications for consultations with other specialists

If there are indications for surgical treatment, a consultation with a cardiac surgeon is recommended.

Physical diagnosis of aortic stenosis

A presumptive diagnosis of severe aortic stenosis can be made based on:

• systolic ejection murmur;
• slowing and decreasing the pulse in the carotid arteries;
• diffuse apical impulse;
• reduction in the intensity of the aortic component in the formation of the second heart sound with possible paradoxical splitting.

Auscultation

Systolic murmur in aortic stenosis is rough, appears soon after the first tone, increases in intensity and reaches a peak by the middle of the ejection period, after which it gradually decreases and disappears before the closure of the aortic valve. The murmur is best heard at the base of the heart, it is well conducted to the vessels of the neck. In CAS, unlike rheumatic and bicuspid aortic stenosis, an increase in the severity of the defect is accompanied by the following changes in systolic murmur:

• reducing its intensity;
• changing the timbre from rough to soft;
• shift of the auscultatory maximum to the apex of the heart (Galaverdin's symptom).

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Electrocardiography in aortic stenosis

The main electrocardiographic indicators of aortic stenosis are signs of left ventricular myocardial hypertrophy, and at the same time their absence does not exclude the presence of even critical aortic stenosis, especially in elderly people. Inversion of the E wave and depression of the ST segment in leads with a cortical position of the ventricular complex are often noted. Depression of the ST segment by more than 0.2 mV is often determined, which is an indirect sign of concomitant left ventricular hypertrophy. Rarely, "infarction-like" ECG changes can be noted, consisting in a decrease in the amplitude of the R wave in the right chest leads.

Atrial fibrillation in patients with non-critical aortic stenosis is indicative of mitral valve involvement. Spread of calcifications from the aortic valve to the cardiac conduction system results in various types of atrioventricular and intraventricular block, usually seen in patients with concomitant mitral valve calcification.

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Chest X-ray

Usually, calcification of the aortic valve and post-stenotic dilatation of the aorta are diagnosed. In the later stages, dilatation of the left ventricular cavity and signs of congestion in the lungs are noted. With concomitant damage to the mitral valve, dilation of the left atrium is determined.

Echocardiography

Recommended for patients with aortic stenosis for the following purposes (Class I).

• Diagnosis and assessment of the severity of aortic stenosis (level of evidence B).
• Evaluation of the severity of left ventricular hypertrophy, chamber size and left ventricular function (level of evidence B).
• Dynamic examination of patients with established aortic stenosis when the severity of clinical signs or symptoms changes (level of evidence B).
• Evaluation of the severity of the defect and left ventricular function in patients with established aortic stenosis during pregnancy (level of evidence B).
• Dynamic monitoring of asymptomatic patients; annually in severe aortic stenosis; every 1-2 years in moderate and every 3-5 years in mild aortic stenosis (level of evidence B).

The severity of aortic stenosis is assessed according to the following criteria.

Severity of aortic stenosis according to 2D echocardiography study

Indicator;		Degree
	I	II	III
Aortic orifice area, cm2	>1.5	1.0-1.5	<1.0
Average pressure gradient on the aortic valve (normal <10), mmHg.	<25	25-40	>40
Maximum blood flow velocity at the atrial valve (normal 1.0-1.7). m/sec	<3.0	3.0-4.0	>4.0
Valve opening index, cm2 / m2	-	-	<.0,6

In some cases, there are significant difficulties in differential diagnosis between rheumatic and calcific aortic stenosis, additional signs of which are indicated in the table.

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Comparative characteristics of rheumatic and calcific aortic stenosis

Signs	Calcific aortic stenosis	Rheumatic aortic stenosis
Age	20-50 years	Over 60 years old
Floor	Predominantly male	Predominantly female
Anamnesis	History of ARF	No history of ARF
Dynamics of disease symptoms	Gradual development of Roberts' triad (angina, syncope, dyspnea)	The symptoms are vague, the disease begins with the appearance of signs of CHF (76-85%)
Features of systolic noise	A rough noise, localized above the aorta and radiating to the vessels of the neck	A soft, often musical murmur (the "cry of a seagull") over the aorta with predominant conduction to the apex of the heart, where it often reaches its maximum (Gailave-din symptom)
II tone	Weakened	Normal or enhanced
IV tone	Rarely	Often
Changes in the aortic valve leaflets	Marginal adhesions, calcification. Immobilization of the valves with subsequent calcification of the fibrous ring of the aortic valve.	Expansion, calcification of the fibrous ring with subsequent reduction in the area of the opening and spread of calcification to the cusps. Compaction and thickening of the cusps (aortic sclerosis) with long-term preserved mobility
Poststenotic dilatation of the aorta	Very rare (<10%)	Often (45-50%)
Damage to other valves	Often	Rarely
Concomitant diseases (arterial hypertension, coronary heart disease)	Rarely (<20%)	Often (>50%)

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Stress testing for aortic stenosis

May be performed in asymptomatic patients with aortic stenosis to detect symptoms or abnormal blood pressure changes (decrease or increase of less than 20 mmHg systolic blood pressure) provoked by physical exercise (level of evidence B). Exercise testing is not indicated in the presence of symptoms of aortic stenosis (level of evidence B).

Coronary angiography

It is indicated for patients with aortic stenosis to verify concomitant coronary artery disease, as well as before aortic valve replacement (AVR) to determine the extent of surgical intervention.

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