Snapshot A 73-year-old man complains of occasional episodes of chest pain, as well as syncope on exertion. On physical exam a systolic crescendo-decrescendo murmur is heard by the upper right sternal border and radiates to the carotids. Introduction Epidemiology aortic stenosis is a major cause of chronic heart failure in elderly patients Causes mechanical wear and tear primary cause in adults unicuspid or bicuspid defects leading to stenosis common cause In pediatric patients associated with Turner's syndrome (XO) rheumatic fever though more often the mitral valve is damaged in RF Presentation Symptoms asymptomatic until very advanced disease SOB angina heart failure once symptoms begin they progress rapidly to death unless treated Physical exam crescendo-decrescendo murmur peaks in early systole radiates to the carotids right upper sternal border (classically) OR left upper sternal border (in some patients) parodoxically split S2 occurs during exhalation (not inhalation) severe stenosis results in a late-peaking murmur diminished A2 component of the 2nd heart sound pulsus parvus et tardus Evaluation Echocardiography is diagnostic gold standard shows thick, calcified aortic valve possibly unicuspid or bicuspid anatomy EKG is usually normal until disease is severe characteristic findings include ventricular hypertrophy increased voltage in limb leads left axis deviation Differential Includes other valvular disorders and other causes of CHF Systolic Murmurs Diastolic Murmurs Hypertrophic obstructive cardiomyopathy midsystolic crescendo-decrescendo murmur heard best at lower left sternal border and apex asymmetric septal hypertropy can radiate to the carotids Mitral regurgitation holosystolic murmur at the apex radiating to the axilla Tricuspid regurgitation soft holosystolic at left sternal border Mitral prolapse apical midsystolic click and a delayed or a late systolic murmur. Aortic regurgitation high pitched blowing early diastolic decrescendo murmur at left sternal border murmur heard at 3rd/4th interspace when patient leading forward holding full expiration Mitral stenosis accentuated S1 diastolic rumble after an opening snap as murmur worsens, snap is heard closer to S2 Treatment Balloon valvuloplasty indicated as temporizing measure before valve replacement Aortic valve replacement indicated in advanced aortic stenosis as definitive treatment Prognosis, Prevention, and Complications Advanced aortic stenosis requires intervention for survival Patients at increased risk of arrhythmias endocarditis left-sided failure LVH angiodysplasia and bleeding in the colon