Aortic stenosis: symptoms, causes, tests and valve replacement

The NHS says symptoms of heart valve disease can include shortness of breath, feeling tired or weak, feeling dizzy, heart palpitations, swollen ankles and feet, and chest pain or discomfort. Some people do not have any symptoms, and it is sometimes found by chance if a doctor hears a heart murmur.

The British Heart Foundation (BHF), describing congenital aortic valve stenosis, says mild to moderate narrowing usually causes no symptoms except a heart murmur, while severe narrowing can cause chest pain (especially when exercising), feeling very tired, difficulty breathing, fainting and palpitations.

The NHS says these symptoms can be caused by many different conditions and do not definitely mean heart valve disease, but it is important to get them checked by a GP. See a GP if you are regularly short of breath, feel tired, weak or dizzy during normal activities, have palpitations that keep coming back or last longer than a few minutes, have swollen ankles or feet, or have chest pain that comes and goes.

The BHF explains that the aortic valve allows blood to flow from the lower left chamber of the heart (the left ventricle) to the main artery supplying blood to the rest of the body (the aorta). In aortic valve stenosis the valve is narrow and cannot open fully, so the heart pumps harder to push blood through it. Over time, the BHF says, this may cause the heart to get bigger and become weaker, and if not treated it can cause problems such as heart failure.

The NHS describes heart valve disease as one or more valves not working as they should. With stenosis the valve does not open fully, and it is most common in the aortic or mitral valves on the left side of the heart.

The NHS says mild heart valve disease without symptoms may not need treatment, with regular check-ups. If you have symptoms or severe disease you may need medicines such as ACE inhibitors, diuretics, beta blockers or anticoagulants, which help with symptoms or complications. The NHS says if you have severe heart valve disease you will usually need surgery to repair the valve, if it is not seriously damaged, or replace it with an artificial valve or one made from human or animal tissue.

The BHF says that for congenital aortic valve stenosis the best treatment is surgery, and that so far medicines have not been shown to work when treating aortic valve stenosis itself. It describes balloon valvuloplasty (a balloon inflated to open the narrowed valve), valve replacement with a mechanical or biological valve (a mechanical valve lasts longer but needs lifelong anticoagulant medicine), and the Ross procedure.

NICE guideline NG208 says that when surgery is agreed, the choice between median sternotomy and minimally invasive surgery should be based on patient characteristics and preferences, and recommends offering TAVI (transcatheter aortic valve implantation), if suitable, to adults with non-bicuspid severe aortic stenosis who are at high surgical risk or for whom surgery is unsuitable.

The NHS says to call 999 or go to A&E if you are struggling to breathe (choking, gasping, unable to speak), have sudden chest pain that spreads to the arms, back, neck or jaw or lasts more than 15 minutes, or have chest pain with breathlessness or palpitations. Do not drive yourself.

The NHS says a GP will listen to your heart, and may arrange tests or refer you to a heart specialist (cardiologist). Tests include an echocardiogram (an ultrasound scan of the heart), a chest X-ray and an ECG. The BHF adds that exercise testing shows whether you get symptoms when doing exercise, and that an MRI or CT scan may be recommended in some cases.

NICE says to offer urgent (within 2 weeks) specialist assessment that includes an echocardiogram to adults with a systolic murmur and exertional syncope (fainting on exertion).

For adults with severe aortic stenosis and no symptoms, NICE says to consider referral for intervention, if suitable, if they have a peak aortic jet velocity of more than 5 m/s, an aortic valve area of less than 0.6 cm2, a left ventricular ejection fraction of less than 55%, a BNP level of more than twice the upper limit of normal, or symptoms unmasked on exercise testing.

The NHS says mild valve disease without symptoms may not need treatment, with regular check-ups to see if it is worsening. NICE says adults with asymptomatic severe valve disease who may need an intervention but do not yet should be offered clinical review every 6 to 12 months, with an echocardiogram. The NHS also says your care team will advise about lifestyle changes and may suggest avoiding strenuous exercise.

The NHS says heart valve disease can be caused by congenital heart disease (being born with the condition), changes to the heart as you get older (particularly if you smoke or have high blood pressure or high cholesterol), conditions that affect the heart such as rheumatic fever, cardiomyopathy or endocarditis, and damage from a heart attack.

The BHF says congenital aortic stenosis at birth is usually caused by a bicuspid aortic valve, which has only 2 flaps instead of 3, and that in most cases it is not known why the valve has not developed normally.

The NHS lists possible complications of heart valve disease as heart failure, atrial fibrillation, stroke and endocarditis, a serious heart infection. If you are pregnant or planning pregnancy with valve disease, get advice from a heart specialist, as pregnancy can worsen symptoms; the NHS says a safe pregnancy is usually possible with extra monitoring and treatment.

On the NHS, the route starts with a GP who listens to your heart and may refer you to a cardiologist. NICE sets out when urgent assessment, monitoring and intervention should be considered, so ask your team where you are on that pathway.

If you see a private cardiologist, ask who will be responsible for reviewing your echocardiograms over time and which options (surgery or TAVI) are being compared for you.