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Symptomatic Moderate AS Assessment — EECC MCQ

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ModerateValvular Heart DiseaseSymptomatic Moderate AS AssessmentEECC

A 70-year-old woman with moderate aortic stenosis and symptoms of angina, syncope, and dyspnoea on exertion has coronary angiography showing non-obstructive CAD. Could her symptoms be from the moderate AS rather than CAD?

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Correct answer: E — Yes — symptom attribution in moderate AS with coexisting conditions is challenging; low-flow states (HFpEF, concentric LVH) can underestimate severity; stress echocardiography to assess symptom reproduction and haemodynamic response, plus CT calcium scoring, can help determine if the AS is truly moderate or underestimated

The traditional teaching that moderate AS is always asymptomatic may be an oversimplification. Factors that can make moderate AS functionally significant: (1) exercise-induced gradient increase (mean gradient may exceed 40 mmHg during exercise even when resting gradient is 25-35 mmHg); (2) coexisting HFpEF or concentric LVH reducing stroke volume and thus gradients at rest; (3) inconsistent echocardiographic grading across examinations. The 2025 ESC VHD Guidelines recommend: (1) exercise echocardiography for symptoms in moderate AS (symptom reproduction + haemodynamic assessment); (2) CT calcium scoring (if calcium is in the 'severe AS' range — >2000 AU men — despite moderate echocardiographic parameters, the AS may be underestimated); (3) careful exclusion of other symptom causes. Intervention for moderate AS is generally only recommended at concomitant cardiac surgery.

Reference: ESC/EACTS (2025): VHD Guidelines