Aortic stenosis stages

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Overview

Aortic stenosis can be classified into 7 stages based on the valve's anatomy, hemodynamics and the patients symptoms.

Stages

Shown below is a table summarizing the stages of aortic stenosis (AS) according to the 2014 AHA/ACC guidelines for the management of patients with valvular heart disease.

Abbreviations: AR: Aortic regurgitation; AS: Aortic stenosis; AVA: Aortic valve area; LV: Left ventricle; LVEF: Left ventricular ejection fraction

STAGE	DEFINITION	VALVE ANATOMY	VALVE HEMODYNAMICS	HEMODYNAMIC CONSEQUENCES	SYMPTOMS
A	At risk of AS	❑ Bicuspid valve ❑ Valve sclerosis	❑ Vmax < 2 m/s	❑ None	❑ None
B	Progressive AS	❑ Mild-to-moderate calcification ❑ Rheumatic valve changes with commissural fusion	❑ Mild AS: Vmax = 2.0-2.9 m/s or mean ΔP < 20 mmHg ❑ Moderate AS: Vmax = 3.0-3.9 m/s or mean ΔP 20-39 mmHg	❑ Early LV diastolic dysfunction may be present ❑ Normal LVEF	❑ None
C1	Asymptomatic severe AS	❑ Severe calcification or congenital stenosis with severely reduced opening	❑ Vmax ≥ 4 m/s or mean ΔP ≥ 40 mmHg ❑ Very severe AS is a Vmax ≥ m/s or mean ΔP ≥ 60 mmHg	❑ LV diastolic dysfunction ❑ Mild left ventricular hypertrophy ❑ Normal LVEF	❑ None ❑ Exercise testing to confirm symptom status
C2	Asymptomatic severe AS with LV dysfunction	❑ Severe calcification or congenital stenosis with severely reduced opening	❑ Vmax ≥ 4 m/s or mean ΔP ≥ 40 mmHg ❑ AVA ≤ 1.0 cm²	❑ LVEF < 50%	❑ None
D1	Symptomatic severe high-gradient AS	❑ Severe calcification or congenital stenosis with severely reduced opening	❑ Vmax ≥ 4 m/s or mean ΔP ≥ 40 mmHg ❑ AVA ≤ 1.0 cm² but may be larger with mixed AS and AR	❑ LV diastolic dysfunction ❑ Left ventricular hypertrophy ❑ May present with pulmonary hypertension	❑ Exertional dyspnea or decreased exercise tolerance ❑ Exertional angina ❑ Exertional syncope or presyncope
D2	Symptomatic severe low-flow/low gradient AS with reduced LVEF	❑ Severe calcification or congenital stenosis with severely reduced motion	❑ AVA ≤ 1.0 cm² with resting aortic Vmax < 4 m/s or mean ΔP ≥ 40 mmHg ❑ Dobutamine stress echo shows AVA ≤ 1.0 cm² with Vmax ≥ 4 m/s at any flow rate	❑ LV diastolic dysfunction ❑ Left ventricular hypertrophy ❑ LVEF <50%	❑ Heart failure ❑ Angina ❑ Syncope or presyncope
D3	Symptomatic severe low gradient with normal LVEF	❑ Severe calcification with severely reduced motion	❑ AVA ≤ 1.0 cm² with Vmax < 4 m/s or mean ΔP ≤ 40 mmHg ❑ AVA ≤ 0.6 cm² ❑ Stroke volume index < 35 mL/m²	❑ Increased LV relative wall thickness ❑ Small LV chamber with low stroke volume ❑ Restrictive diastolic filling ❑ LVEF ≥ 50%	❑ Heart failure ❑ Angina ❑ Syncope or presyncope