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.
Key red flags
Orthopnoea, crackles, raised JVP and oedema suggest decompensation and require urgent assessment rather than routine surveillance.
Investigation priorities
Define valve anatomy, Vmax, mean gradient, valve area, LVEF, stroke volume, other valves and aortic dimensions.
Management branches
Severe stenosis is accompanied by exertional dyspnoea, angina, syncope or heart failure not better explained otherwise.
- Confirm symptom–valve concordance and severity promptly with specialist echocardiography; do not wait for the next surveillance scan.
- Refer to a multidisciplinary heart valve team for intervention assessment and evaluate frailty, comorbidity, coronary/aortic anatomy and procedural risk.
Key medicines
FurosemideFor acute oedema, 20–50 mg IV initially; inject slowly and do not exceed 4 mg/min. Reassess before any repeat dose.