1. Physical Exam: Auscultation reveals a crescendo-decrescendo murmur in the right upper sternal border often with radiation to the neck. In severe AS, the murmur peaks later in systole due to the small orifice area and is diminished in intensity due to a low stroke volume. Carotid upstrokes are diminished in volume with a slow rate of rise (pulsus parvus et tardus). The apical impulse is prominent and displaced.
2. EKG changes including left ventricular (LV) hypertrophy with a left atrial abnormality are nonspecific for aortic stenosis. A chest radiograph  may show aortic calcification or a boot-shaped heart suggestive of concentric hypertrophy and is also nonspecific.
3. Echocardiography is the principle tool of diagnosis. It is used to assess aortic valve area and calcification, transvalvular gradient, LV function, and the extent of hypertrophy. The criteria to diagnosis aortic stenosis in patients with normal LV function are outlined in Table 1⁽³⁾.

Serial Echocardiography:

The 2014 AHA/ACC valvular guideline recommendations for serial echocardiography in patients with aortic stenosis⁽⁴⁾:

1. Mild AS: TTE recommended every 3 to 5 years.
2. Moderate AS: TTE recommended every 1 to 2 years.
3. Asymptomatic severe AS TTE is recommended every 6 to 12 months.
4. Change in symptoms or signs suggestive of worsening cardiac status: reassess with TTE.

When ordering serial diagnostic testing on geriatric patients, it is important to consider the context of the patients overall goals of care and quality of life.  Communication between the patient’s primary care provider and cardiologist is encouraged to develop a plan of care to address the patient’s needs and goals. The average cost to perform a TTE ranges from $1000-$2000, with professional fees to interpret the images ranging from $300-$500. These services when performed as an outpatient are covered under Medicare Part B.

Asymptomatic vs Symptomatic:

Asymptomatic patients with severe aortic stenosis carry a risk of sudden cardiac death of 2% per year.  The hallmark symptoms of aortic stenosis are angina, syncope and congestive heart failure.  Symptomatic patients with aortic stenosis have a mortality rate of 25% per year or about 2% a month ⁽⁵⁾.  Symptomatic patients have a high mortality rate and require prompt cardiology consultation.

Symptomatic patients with aortic stenosis presenting with

1. angina have a mortality risk of 50% in 5 years.
2. syncope have a mortality risk of 50% in 3 years.
3. heart failure have a mortality risk of 50% in 2 years⁽⁶⁾.