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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Aortic stenosis

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Escalate

Call 999 for syncope with ongoing compromise, new chest pain at rest, severe breathlessness, pulmonary oedema or shock. Acute decompensation in severe aortic stenosis needs monitored specialist care because hypotension and abrupt preload reduction may be poorly tolerated.

Synopsis

Recognise severe aortic stenosis, distinguish high-gradient from low-flow disease, and choose surveillance, urgent stabilisation and valve-team referral routes in UK practice.

  • The classic symptoms are exertional breathlessness, angina and syncope; any symptom attributable to severe stenosis changes prognosis and prompts intervention assessment.
  • The murmur is harsh, ejection systolic and usually radiates to the carotids; a slow-rising low-volume pulse and soft second heart sound support advanced disease.
  • Severe high-gradient stenosis is usually Vmax 4.0 m/s or more, mean gradient 40 mmHg or more, or valve area 1.0 cm2 or less, interpreted together rather than in isolation.
  • A low gradient does not exclude severe stenosis when stroke volume or LVEF is reduced; dobutamine stress echo or CT valve-calcium scoring can resolve discordance.
  • There is no medicine that relieves the fixed obstruction or improves survival in severe aortic stenosis; definitive treatment is valve replacement.
  • NICE recommends clinical review and echocardiography every 6–12 months for asymptomatic severe valve disease when intervention would be suitable.
  • SAVR and TAVI choice belongs to a multidisciplinary valve team and incorporates age, anatomy, surgical risk, frailty, coronary/aortic disease, durability and patient preference.
  • Very severe asymptomatic disease, an abnormal exercise test or LV systolic impairment can justify intervention before spontaneous symptoms appear.

Key red flags

Heart-failure phenotype

Orthopnoea, crackles, raised JVP and oedema suggest decompensation and require urgent assessment rather than routine surveillance.

Investigation priorities

01
Transthoracic echocardiographyFirst step

Define valve anatomy, Vmax, mean gradient, valve area, LVEF, stroke volume, other valves and aortic dimensions.

Management branches

symptomaticSymptomatic severe aortic stenosis

Severe stenosis is accompanied by exertional dyspnoea, angina, syncope or heart failure not better explained otherwise.

  1. Confirm symptom–valve concordance and severity promptly with specialist echocardiography; do not wait for the next surveillance scan.
  2. Refer to a multidisciplinary heart valve team for intervention assessment and evaluate frailty, comorbidity, coronary/aortic anatomy and procedural risk.
  3. Offer valve replacement when benefit is expected: SAVR or TAVI according to age, anatomy, durability, access and patient preference; address coronary disease at the same decision.
  4. If definitive intervention is temporarily impossible, use cautious symptom treatment and consider balloon valvuloplasty only as a specialist bridge or palliation.

Key medicines

FurosemideFor acute oedema, 20–50 mg IV initially; inject slowly and do not exceed 4 mg/min. Reassess before any repeat dose.Use especially cautiously in severe aortic stenosis because hypovolaemia and hypotension can reduce coronary perfusion; monitor BP, urine output, renal function, sodium and potassium. The dose is from the SmPC, not a Resuscitation Council peri-arrest regimen.
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Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG208: Heart valve disease presenting in adultsUK referral, intervention and monitoring recommendations.
  • ESC/EACTS 2025 valvular heart disease guidelineContemporary imaging, intervention and Heart Team principles.
  • ESC: Aortic stenosis diagnosis criteriaSeverity and discordant low-flow assessment.
  • NHS: Heart valve diseaseSymptoms and urgent patient-facing advice.
  • NHS England: TAVI and SAVR position statementUK multidisciplinary procedure selection.
  • eMC: Furosemide injection SmPCIV adult dosing and administration cautions.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom