50% of untreated patients with severe aortic stenosis will die within two years

By the time symptoms appear in a patient with aortic stenosis, it’s often so late in the disease progression, that they may only have a few years left.

Severe inoperable aortic stenosis has a prognosis of about three years— worse than many metastatic cancers, including lung, bowel, breast, ovarian and prostate, says Professor Andrew Sindone, who is Director of the Heart Failure Unit and Department of Cardiac Rehabilitation at Concord Hospital and Head of Department of Cardiology at Ryde Hospital.

New prevalence data shows that many are still going undiagnosed and untreated—90% of those with severe symptomatic aortic stenosis don’t get aortic valve replacement.

Fortunately, aortic stenosis can be treated effectively with either surgical aortic valve replacement or transcutaneous aortic valve implantation, even when severe. However, operating early reduces the risks of sudden death.

That’s why it’s so important for doctors to identify who may be at risk, check for signs and refer during the period where intervention is most beneficial, he says.

“Once they develop symptoms, that’s almost an emergency. We should be very, very quickly sending the patient off to see a cardiologist and considering intervention,” Professor Sindone says.

Most patients experience a latent period where increasing obstruction and myocardial overload occur, and by the time symptoms appear, the chance of dying increases dramatically.

An analysis of 3 million echocardiograms from National Echo Database of Australia (NEDA), showed that aortic stenosis doesn’t have to be as severe as previously thought to increase mortality risk.

“That latent period is the time we should be managing these patients, not waiting until they start getting symptoms,” Professor Sindone says.

He notes that aortic stenosis is also more common than many people realise, and increasing in prevalence.

One in eight people over the age of 75 have aortic stenosis.

Aortic stenosis can be caused by atherosclerosis, rheumatic fever, radiotherapy for lung cancer, breast cancer or lymphoma and congenital heart disease.

It’s more prevalent in people who are over the age of 65, and other risk factors include hypertension, diabetes, smoking, CKD and CAD.

That’s why it’s so crucial to check for the signs in those who may be at risk.

“The most important thing is to use your stethoscope and listen,” Professor Sindone says.

How can you tell when someone has severe aortic stenosis?

Right now in Australia, more than 97,000 people have severe aortic stenosis. Two out of three of them have symptoms. These can include chest pain, reduced physical activity, palpitations, feeling faint or syncope, particularly on exertion, fatigue, and shortness of breath.

“So those signs may be nonspecific, but if you don’t think about aortic stenosis you’ll never find it,” he says.

Importantly, one out of three don’t have symptoms, so identifying and treating that group before symptoms develop is key to improving outcomes.

If you hear a murmur and you’re not sure, order an ECG or refer to a cardiologist, he says.

Six signs of severity

• the length of the murmur
• the lateness of the peak
• the presence of a fourth heart sound
• the presence of a thrill
• a soft aortic component of the second heart sound
• narrow pulse pressure (that means the difference between systolic and diastolic blood pressure is less than 40 mmHg)

The more of these signs the person has, the more likely the aortic stenosis is severe.

One that’s not on the list: the loudness of the murmur. That is not a sign of severity, he adds.

To sum up? “Listen, suspect, refer,” Professor Sindone says. “Listen to the heart of all patients over the age of 65 and if you think that there is a murmur consider investigation and referral.”

To hear more, register here for Healthed’s 4 April webcast, where Professor Sindone will talk about aortic stenosis in much more detail.