A 70-year-old man presents with progressively worsening exertional dyspnea, angina, and two syncopal episodes. On examination, there is a harsh crescendo-decrescendo systolic murmur radiating to the carotids, with a slow rising carotid pulse (pulsus parvus et tardus). Echo shows calcified aortic valve with mean gradient 55 mmHg and AVA 0.7 cm². What is the most appropriate next step?

• A Aortic valve replacement (surgical or transcatheter) ✓
• B Start ACE inhibitor and follow up in 1 year
• C Balloon aortic valvuloplasty as definitive treatment
• D Intensify diuretic therapy and reassess in 3 months

Explanation

Severe symptomatic aortic stenosis (AVA < 1.0 cm², mean gradient > 40 mmHg with symptoms of angina, syncope, or heart failure) carries a median survival of only 1–3 years without valve replacement. The presence of all three classic symptoms confirms symptomatic severe AS; aortic valve replacement (AVR — surgical for low/intermediate surgical risk, TAVR for high/prohibitive surgical risk) is the definitive Class I indication. Medical therapy does not alter the disease course and vasodilators are potentially harmful.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.