Aortic Sclerosis

Thickening and focal calcification of the aortic valve leaflets without significant obstruction: peak aortic velocity less than 2.5 m/s and normal leaflet opening.

• Present in about 25% of adults older than 65 and 40 to 50% of those older than 80.
• Mechanism: lipid deposition, inflammation and osteogenic calcification of the leaflets, sharing risk factors with atherosclerosis (age, hypertension, diabetes, smoking, raised LDL cholesterol, chronic kidney disease).
• About 10 to 15% progress to stenosis within 5 years. The condition marks a roughly 1.5-fold higher risk of cardiovascular events, mainly because of coexisting coronary disease.

• Asymptomatic.
• Soft ejection systolic murmur (grade 1 to 2), early to mid-peaking, loudest at the right upper sternal edge, with little or no radiation to the carotids.
• Normal carotid upstroke, normal second heart sound, no ejection click, no diastolic murmur.
• Differential diagnosis: early aortic stenosis, hypertrophic cardiomyopathy, flow murmur, mitral regurgitation, pulmonary stenosis, ventricular septal defect.
• Complications: progression to aortic stenosis (about 1 to 2% of patients per year), a raised risk of myocardial infarction and cardiovascular death (relative risk about 1.5), rarely endocarditis, and extension of calcium into the conduction system.

• Transthoracic echocardiography: bright, thickened leaflets with preserved opening, peak velocity less than 2.5 m/s, no commissural fusion, normal left ventricular size and function.
• ECG and chest X-ray are usually normal.
• Assess overall cardiovascular risk: blood pressure, lipids, glucose, renal function.

• No drug has been shown to prevent progression to stenosis.
• Treat cardiovascular risk: blood pressure less than 130/80 mmHg with amlodipine 5 to 10 mg daily or ramipril 2.5 to 10 mg daily; atorvastatin 20 to 40 mg daily when overall risk warrants it; smoking cessation, glycaemic control, exercise, weight control. Give aspirin 75 to 100 mg daily only when atherosclerotic disease is established.
• Surveillance: echocardiography every 3 to 5 years if asymptomatic; sooner for a louder or later peaking murmur or new symptoms.
• Antibiotic prophylaxis for dental procedures is not needed; maintain good oral hygiene.
• Special groups: elderly (usually incidental; do not over investigate); chronic kidney disease (faster calcification; control phosphate and avoid calcium excess); pregnancy (no specific management).
• Red flags: exertional dyspnoea, angina, syncope, soft or single second heart sound, slow rising pulse, or a velocity rise to 2.5 m/s or more. Refer for assessment of aortic stenosis.
• Follow up: annual clinical review with risk factor control.