Aortic stenosis classification: Difference between revisions

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{{Aortic stenosis}}
{{Aortic stenosis}}
{{CMG}}; {{AOEIC}} [[Priyamvada Singh|Priyamvada Singh, MBBS]]  [mailto:psingh13579@gmail.com]; '''Assistant Editor-In-Chief:''' [[Kristin Feeney|Kristin Feeney, B.S.]] [mailto:kfeeney@elon.edu]; {{USAMA}}
{{CMG}}; {{AE}}{{MC}}


==Overview==
==Overview==
Aortic stenosis can be classified broadly in two main categories: acquired and congenital. Further classification can be applied based on the origin of the stenosis such as [[Rheumatic fever|acquired rheumatic]], [[bicuspid aortic valve|congenital bicuspid]], [[Subaortic stenosis|congenital subaortic]], [[Subaortic stenosis|congenital subvalvular]], and [[Supravalvular aortic stenosis|congenital supravalvular]].<ref name=abc> Hameed, Afshan B., and Shahbudin H. Rahimtoola. "Congenital Aortic Stenosis: Pregnancy Is Another Dimension." Journal of the American College of Cardiology 68.16 (2016): 1738-1740.</ref><ref name="pmid15468729">{{cite journal| author=Nasonova VA, Kuz'mina NN, Belov BS| title=[Present-day classification and nomenclature of rheumatic fever]. | journal=Klin Med (Mosk) | year= 2004 | volume= 82 | issue= 8 | pages= 61-6 | pmid=15468729 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15468729  }} </ref>
 
According to the 2020 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease, there are 4 stages of aortic stenosis based on the valve anatomy, valve hemodynamics, the left ventricular and vascular consequences of aortic obstruction, and the symptoms. The stages include at risk of AS, progressive hemodynamic obstruction, severe asymptomatic AS, and symptomatic AS.


==Classification==
==Classification==
===Acquired Aortic Stenosis===
Acquired aortic stenosis in adults has two major causes:


*Calcific degenerative disease of a structurally normal trileaflet valve:  
According to the 2020 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease, there are 4 stages of aortic stenosis based on the valve anatomy, valve hemodynamics, the left ventricular and vascular consequences of aortic obstruction, and the symptoms of the patient:
**Calcific aortic disease has many of the same risk factors as atherosclerotic disease and it is characterized by fat deposition, inflammation, and calcification. It is also frequently observed among patients with [[renal failure]].<ref name="pmid11527641">{{cite journal| author=Agmon Y, Khandheria BK, Meissner I, Sicks JR, O'Fallon WM, Wiebers DO et al.| title=Aortic valve sclerosis and aortic atherosclerosis: different manifestations of the same disease? Insights from a population-based study. | journal=J Am Coll Cardiol | year= 2001 | volume= 38 | issue= 3 | pages= 827-34 | pmid=11527641 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11527641  }} </ref>
* '''A''': Patient at risk of AS
* '''B''': Progressive hemodynamic obstruction
* '''C''': Severe asymptomatic AS
* '''D''': Symptomatic AS
 
Hemodynamic severity is assessed by transaortic maximum velocity or mean pressure gradient in the presence of a normal transaortic flow rate. However, some patients with AS have a low transaortic flow rate due to:
* LV systolic dysfunction with a reduced LV ejection fraction (designated as D2)
* Small hypertrophied LV with a low stroke volume (designated as D3) <ref name="pmid33332150">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e72–e227 |date=February 2021 |pmid=33332150 |doi=10.1161/CIR.0000000000000923 |url=}}</ref>


*Valve disease resulting from [[rheumatic fever]]:  
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
**Rheumatic valve disease involves fusion of the commissures between the leaflets resulting in a small central orifice.<ref name="pmid15468729">{{cite journal| author=Nasonova VA, Kuz'mina NN, Belov BS| title=[Present-day classification and nomenclature of rheumatic fever]. | journal=Klin Med (Mosk) | year= 2004 | volume= 82 | issue= 8 | pages= 61-6 | pmid=15468729 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15468729  }} </ref>
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Stage
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Definition
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Valve Anatomy
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Valve Hemodynamics
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Hemodynamic Consequences
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Symptoms


===Congenital Left-Sided Outflow Obstruction===
|-
Congenital left-sided outflow obstruction can be due to a variety of conditions, all of which culminate in obstruction of the left ventricular outflow tract. These conditions include:<ref name="pmid14275999">{{cite journal| author=EDWARDS JE| title=PATHOLOGY OF LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION. | journal=Circulation | year= 1965 | volume= 31 | issue= | pages= 586-99 | pmid=14275999 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14275999  }} </ref>
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''A'''
#[[Bicuspid aortic valve]]
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''At risk of AS'''
#Unicuspid aortic valve
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
#[[Hypoplasia]] of the annulus
* Bicuspid aortic valve (or other congenital valvular anomalies)
#[[Subaortic stenosis]]
* Aortic valve sclerosis
#[[Subvalvular aortic stenosis]]
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
#[[Supravalvular aortic stenosis]]
* Aortic Vmax <2 m/s
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* None
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* None
|-
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''B'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''Progressive AS'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Mild to moderate leaflet calcification of a bicuspid or trileaflet valve with some reduction in systolic motion or
* Rhematic valve changes with commissural fusion
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* '''Mild AS''': Aortic Vmax 2.0-2.9 m/s or mean ΔP <20 mmHg
* '''Moderate AS''': Aortic Vmax 3.0-3.9 m/s or mean ΔP 20-39 mmHg
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Early LV diastolic dysfunction may be present
* Normal LVEF
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* None
|-
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''C:'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''Asymptomatic severe AS'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
|-
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''C1'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''Asymptomatic severe AS'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Aortic Vmax ≥ 4 m/s or mean ΔP ≥40 mmHg
* AVA typically ≤ 1.0 cm<sup>2</sup> (or AVAi ≤ 0.6 cm<sup>2</sup>/m<sup>2)
* Very severe AS: Aortic Vmax ≥ 5 m/s or mean ΔP ≥60 mmHg
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* LV diastolic dysfunction
* Mild LV hypertrophy
* Normal LVEF
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* None (Exercise testing is reasonable to confirm)
|-
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''C2'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''Asymptomatic severe AS with LV dysfunction'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Aortic Vmax ≥ 4 m/s or mean ΔP ≥40 mmHg
* AVA typically  ≤ 1.0 cm<sup>2</sup> (or AVAi ≤ 0.6 cm<sup>2</sup>/m<sup>2)
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* LVEF <50%
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* None
|-
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''D:'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''Symptomatic severe AS'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
|-
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''D1'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''Symptomatic severe high-grade AS'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Aortic Vmax ≥ 4 m/s or mean ΔP ≥40 mmHg
* AVA typically ≤ 1.0 cm<sup>2</sup> (or AVAi ≤ 0.6 cm<sup>2</sup>/m<sup>2</sup>) but may be larger with mixed AS/AR
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* LV diastolic dysfunction
* LV hypertrophy
* Pulmonary hypertension may be present
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Exertional dyspnea or decreased exercise tolerance
* Exertional angina
* Exertional syncope/presyncope
|-
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''D2'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''Symptomatic severe low-flow/low-gradient AS with reduced LVEF'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Severe leaflet calcification with severely reduced leaflet motion
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* AVA ≤1.0 cm<sup>2</sup> with resting aortic Vmax <4 m/s or mean ΔP <40 mmHg
* Dobutamine stress echocardiography shows AVA ≤ 1.0 cm<sup>2</sup> with Vmax ≥4 m/s at any flow rate
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* LV diastolic dysfunction
* LV hypertrophy
* LVEF <50%
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Heart failure
* Angina
* Syncope/presyncope
|-
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''D3'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''Symptomatic severe low-gradient AS with normal LVEF or paradoxical low-flow severe AS'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Severe leaflet calcification with severely reduced leaftlet motion
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* AVA ≤1.0 cm<sup>2</sup> with aortic Vmax <4 m/s or mean ΔP <40 mmHg
* AVAi ≤0.6 cm<sup>2</sup>/m<sup>2</sup> and
* Stroke volume index <35 ml/m<sup>2</sup>
* Measured when patient is normotensive (systolic BP <140 mmHg)
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Increased LV relative wall thickness
* Small LV chamber with low stroke volume
* Restrictive diastolic filling
* LVEF ≥50%
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Heart failure
* Angina
* Syncope/presyncope
|-
|}


==References==
==References==

Latest revision as of 02:52, 29 June 2022



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

Overview

According to the 2020 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease, there are 4 stages of aortic stenosis based on the valve anatomy, valve hemodynamics, the left ventricular and vascular consequences of aortic obstruction, and the symptoms. The stages include at risk of AS, progressive hemodynamic obstruction, severe asymptomatic AS, and symptomatic AS.

Classification

According to the 2020 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease, there are 4 stages of aortic stenosis based on the valve anatomy, valve hemodynamics, the left ventricular and vascular consequences of aortic obstruction, and the symptoms of the patient:

  • A: Patient at risk of AS
  • B: Progressive hemodynamic obstruction
  • C: Severe asymptomatic AS
  • D: Symptomatic AS

Hemodynamic severity is assessed by transaortic maximum velocity or mean pressure gradient in the presence of a normal transaortic flow rate. However, some patients with AS have a low transaortic flow rate due to:

  • LV systolic dysfunction with a reduced LV ejection fraction (designated as D2)
  • Small hypertrophied LV with a low stroke volume (designated as D3) [1]
Stage Definition Valve Anatomy Valve Hemodynamics Hemodynamic Consequences Symptoms
A At risk of AS
  • Bicuspid aortic valve (or other congenital valvular anomalies)
  • Aortic valve sclerosis
  • Aortic Vmax <2 m/s
  • None
  • None
B Progressive AS
  • Mild to moderate leaflet calcification of a bicuspid or trileaflet valve with some reduction in systolic motion or
  • Rhematic valve changes with commissural fusion
  • Mild AS: Aortic Vmax 2.0-2.9 m/s or mean ΔP <20 mmHg
  • Moderate AS: Aortic Vmax 3.0-3.9 m/s or mean ΔP 20-39 mmHg
  • Early LV diastolic dysfunction may be present
  • Normal LVEF
  • None
C: Asymptomatic severe AS
C1 Asymptomatic severe AS
  • Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening
  • Aortic Vmax ≥ 4 m/s or mean ΔP ≥40 mmHg
  • AVA typically ≤ 1.0 cm2 (or AVAi ≤ 0.6 cm2/m2)
  • Very severe AS: Aortic Vmax ≥ 5 m/s or mean ΔP ≥60 mmHg
  • LV diastolic dysfunction
  • Mild LV hypertrophy
  • Normal LVEF
  • None (Exercise testing is reasonable to confirm)
C2 Asymptomatic severe AS with LV dysfunction
  • Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening
  • Aortic Vmax ≥ 4 m/s or mean ΔP ≥40 mmHg
  • AVA typically ≤ 1.0 cm2 (or AVAi ≤ 0.6 cm2/m2)
  • LVEF <50%
  • None
D: Symptomatic severe AS
D1 Symptomatic severe high-grade AS
  • Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening
  • Aortic Vmax ≥ 4 m/s or mean ΔP ≥40 mmHg
  • AVA typically ≤ 1.0 cm2 (or AVAi ≤ 0.6 cm2/m2) but may be larger with mixed AS/AR
  • LV diastolic dysfunction
  • LV hypertrophy
  • Pulmonary hypertension may be present
  • Exertional dyspnea or decreased exercise tolerance
  • Exertional angina
  • Exertional syncope/presyncope
D2 Symptomatic severe low-flow/low-gradient AS with reduced LVEF
  • Severe leaflet calcification with severely reduced leaflet motion
  • AVA ≤1.0 cm2 with resting aortic Vmax <4 m/s or mean ΔP <40 mmHg
  • Dobutamine stress echocardiography shows AVA ≤ 1.0 cm2 with Vmax ≥4 m/s at any flow rate
  • LV diastolic dysfunction
  • LV hypertrophy
  • LVEF <50%
  • Heart failure
  • Angina
  • Syncope/presyncope
D3 Symptomatic severe low-gradient AS with normal LVEF or paradoxical low-flow severe AS
  • Severe leaflet calcification with severely reduced leaftlet motion
  • AVA ≤1.0 cm2 with aortic Vmax <4 m/s or mean ΔP <40 mmHg
  • AVAi ≤0.6 cm2/m2 and
  • Stroke volume index <35 ml/m2
  • Measured when patient is normotensive (systolic BP <140 mmHg)
  • Increased LV relative wall thickness
  • Small LV chamber with low stroke volume
  • Restrictive diastolic filling
  • LVEF ≥50%
  • Heart failure
  • Angina
  • Syncope/presyncope

References

  1. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C (February 2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e72–e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check |pmid= value (help).

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