Makindo Medical Notes

Related Subjects: |Aortic Anatomy |Acute Coronary Syndrome (ACS) General |Aortic Dissection |Acute Heart Failure and Pulmonary Oedema |Aortic Regurgitation (Incompetence) |Aortic Stenosis |Aortic Sclerosis |Transcatheter aortic valve implantation (TAVI)

🔎 Introduction

Aortic sclerosis is thickening and calcification of the aortic valve leaflets without significant obstruction. It is common in older adults, usually asymptomatic, but signals increased cardiovascular risk and may progress to aortic stenosis over time.

📊 Epidemiology

• Prevalence: ~25% of those >65 years; up to 40% of those >75 years.
• More common in men than women.
• Often coexists with hypertension and coronary artery disease.

⚙️ Pathophysiology

• Valve thickening/calcification with preserved cusp mobility.
• Endothelial injury → lipid deposition, inflammation, fibrosis, and calcification.
• Key distinction:
  • Sclerosis: Peak jet velocity <2.0 m/s; normal valve area; no gradient.
  • Stenosis: Peak velocity ≥2.5 m/s, mean gradient ≥20 mmHg, reduced valve area, LV pressure load.

🧬 Risk Factors

• Ageing (most important).
• Shared with atherosclerosis: HTN, hyperlipidaemia, diabetes, smoking, CKD.
• Male sex.
• History of rheumatic fever (rare in UK now).

🩺 Clinical Features

• Usually asymptomatic.
• Murmur: Soft ejection systolic murmur at right upper sternal edge; may radiate to carotids.
• No pulse delay, no heave, no LV hypertrophy.
• ⚠️ Red flags suggesting stenosis: exertional angina, syncope, dyspnoea → urgent echo referral.

🔬 Investigations

• ECG: Often normal; LVH only if coexistent hypertension.
• CXR: May show valve/root calcification.
• Echocardiography (Gold Standard):
  • Thickened leaflets, preserved excursion.
  • AVA normal, peak velocity <2 m/s.
• Bloods: Lipids, glucose, renal function (to guide risk modification).

🆚 Key Differentials

🛠️ Management

• No direct valve intervention unless progression to stenosis.
• Risk factor modification:
  • Smoking cessation, healthy diet, regular exercise.
  • Treat HTN, diabetes, and hyperlipidaemia (statins as per NICE CG181).
• Monitoring: Clinical review + repeat echo every 2–5 years.
• Education: Reassure that sclerosis itself is benign, but advise patients to report chest pain, syncope, or breathlessness.
• Medications: No proven therapy halts sclerosis. Statins/ACE inhibitors studied but inconclusive.

📈 Prognosis

• Benign in isolation, but an independent marker of systemic atherosclerosis.
• Associated with higher rates of MI, stroke, and cardiovascular death.
• ~10–15% progress to clinically significant aortic stenosis within 5 years.

📚 References

• Otto CM, Lind BK, Kitzman DW, et al. NEJM 1999;341:142–147.
• Stewart BF, Siscovick D, Lind BK, et al. JACC 1997;29:630–634.
• NICE CG181: Cardiovascular risk assessment and lipid modification.