Hemodynamic Patterns for Symptomatic Presentations of Severe Aortic Stenosis

Study Questions:

Are aortic stenosis (AS) severity and/or aortic valve hemodynamics associated with the nature of symptoms at presentation?


From 2003 to 2009 at a single institution, records were analyzed for 498 patients (58.4% men, ages 66 ± 12 years) with severe AS and normal left ventricular (LV) ejection fraction who had undergone comprehensive echocardiography for AS. Patients were divided into four groups based on presenting symptom(s): 341 asymptomatic patients, 15 patients with syncope, 110 with dyspnea, and 32 with chest pain. Echocardiographic measurements of cardiac structure, function, and hemodynamics were compared between groups.


Aortic valve mean pressure gradient and aortic valve area were 57.1 ± 15.2 mm Hg and 0.74 ± 0.19 cm2, respectively. AS severity based on mean gradient and aortic valve area was similar among four groups. Compared with the asymptomatic group, symptomatic patients were older, and had lower cardiac output, and higher E/e’ ratio. Patients with syncope had smaller LV dimension, stroke volume, cardiac output, left atrial volume index, and E/e’ ratio. Conversely, patients with dyspnea had worse LV diastolic function, with the largest left atrial volume index and highest E/e’ ratio.


Among patients with severe AS, symptoms appeared to be associated with specific hemodynamic patterns: smaller LV cavity and reduced cardiac output were associated with syncope, and more severe LV diastolic dysfunction was associated with dyspnea. The authors proposed that comprehensive hemodynamic assessment, including diastolic function and stroke volume, should be evaluated in addition to aortic valve area and pressure gradient for assessment of AS.


Multiple factors influence the presence and nature of symptoms associated with AS, almost certainly including the severity of AS, patient physical activity, and how medical professionals elicit the presence of symptoms. This study found that specific symptoms (angina, dyspnea, syncope) are associated with various underlying factors on echocardiography/Doppler, predominantly related to LV size, cardiac output, and diastolic function. The associations are of interest from a pathophysiologic standpoint. However, without demonstration of differences in outcome based on them, it is difficult to suggest that those echo/Doppler variables should play a role in patient management.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Echocardiography/Ultrasound

Keywords: Echocardiography, Doppler, Ventricular Function, Left, Chest Pain, Syncope, Cardiac Output, Stroke Volume, Dyspnea, Hemodynamics, Echocardiography

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