Elderly: exertional dyspnea, syncope, angina; crescendo-decrescendo systolic murmur 2nd R ICS → carotids; louder w/ squatting, softer w/ Valsalva
Bedside maneuvers → then Echocardiogram (diagnostic: valve area, gradient, LVH)
Symptomatic severe AS → Aortic Valve Replacement (surgical AVR or TAVR) — before LV dilation
Valve choice: bioprosthetic preferred in elderly (no lifelong warfarin); mechanical needs INR 2–3
Order set
- Echo (gradient, valve area, EF)
- ECG
- CXR
- Coronary angiography pre-op
Criteria
AdmitSyncope, heart failure, or ACS-like presentation
ICUHaemodynamic instability peri-procedure
DischargeSymptoms controlled and valve intervention plan in place
Never
- Give diuretics / nitrates / vasodilators — ↓ LV filling → syncope/arrest
- Use balloon valvuloplasty (valve re-stenoses quickly)
Key
- No medical therapy prolongs survival — replacement is the answer once symptomatic.
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Syncope
- Angina
- Heart failure — all mark severe symptomatic AS
Differentials
- HOCM
- Mitral regurgitation
- Aortic sclerosis
Common mistakes
- Vasodilators/diuretics dropping preload
- Delaying valve referral
Disposition & follow-up
Symptomatic severe → prompt surgical/TAVR referral.
Discharge package
MedicationsTreat comorbid HTN cautiously; avoid excess vasodilators
Follow-upCardiology; timing of valve intervention
Warning symptomsExertional syncope, angina, breathlessness
💊 Treatment detail — doses & preparation
Vasodilator cautionsafety
DoseAvoid nitrates/ACEi in severe AS (fixed output — precipitous hypotension)
Preparation—
MonitorEcho gradient + BP tolerance before any afterload reduction
Aortic valve replacementdefinitive
DoseSAVR (young/low-risk) or TAVR (older/high-risk) once symptomatic severe
PreparationPre-op: echo, CT annulus sizing, coronary assessment
MonitorWatch for heart block post-TAVR
📖 ESC/EACTS Valvular Heart DiseaseReviewed July 2026