Aortic stenosis stages

Aortic Stenosis Microchapters
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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]; Usama Talib, BSc, MD [3]

Overview

Aortic stenosis can be classified into 7 stages based on the valve's anatomy and hemodynamics as well as 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	SYMPTOMS	VALVE ANATOMY	VALVE HEMODYNAMICS	HEMODYNAMIC CONSEQUENCES
A	At risk of AS	• None	• Bicuspid valve • Valve sclerosis	• Vmax < 2 m/s	• None
B	Progressive AS	• None	• 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
C1	Asymptomatic severe AS	• None • Exercise testing to confirm symptom status	• 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
C2	Asymptomatic severe AS with LV dysfunction	• None	• Severe calcification or congenital stenosis with severely reduced opening	• Vmax ≥ 4 m/s or mean ΔP ≥ 40 mmHg • AVA ≤ 1.0 cm²	• LVEF < 50%
D1	Symptomatic severe high-gradient AS	• Exertional dyspnea or decreased exercise tolerance • Exertional angina • Exertional syncope or presyncope	• 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
D2	Symptomatic severe low-flow/low gradient AS with reduced LVEF	• Heart failure • Angina • Syncope or presyncope	• Severe calcification or congenital stenosis with severely reduced leaflet 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%
D3	Symptomatic severe low gradient with normal LVEF	• Heart failure • Angina • Syncope or presyncope	• Severe calcification with severely reduced leaflet 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%