Chest pain in aortic stenosis: novel diagnostic and therapeutic data

By Dennis Cokkinos

Angina pectoris (AP) in aortic stenosis (AS) is not unusual. It can be seen in up to 75% of patients. It is associated with coronary artery disease (CAD) in 50-74% of patients; it’s for diagnosing CAD sensitivity 78% and specificity 82%. When AP is seen in the absence of CAD, reduced coronary flow reserve is the cause. Associated features are an increased LV systolic pressure and increased wall stress mechanism. Peak systolic flow is lower, while diastolic flow shows slower acceleration and faster deceleration.

Abnormal cardiac-coronary coupling is the main problem while microvascular disease is absent; ischemia, enhanced coagulation and oxidative stress have also been found. We have also found many biomarkers common in both AS and atherosclerosis (inflammation, fibrosis, proliferation, calcification).

Apart from coronary arteriography, stress myocardial scintigraphy is the method of choice for diagnosing CAD in AS. It is not needed in patients without AP. Serum biomarkers may not be of value because both NT-proBNP and hsTnT can be increased due to wall stress and fibrosis. Treatment of CAD without intervention in the aortic valve is warranted only when the former is severe and the latter mild; β-blockers may be used.

When surgical aortic valve replacement is indicated, CAD should preferably be combined with CABG. When TAVR is indicated, PCI should be preferred. It is arguable if it should be done at the same time setting or after TAVR. It is not usually advisable to perform it before TAVR. One point of concern is that with TAVR troponin elevation is seen in ~90% of patients. As earlier correction of AS is gradually emerging, indication for coronary revascularization may change. Usually, in severe AS and AP without significant CAD, correction of the valve problem would suffice. However, reversal of coronary flow abnormalities has not been adequately studied.


AP is common in AS and usually due to CAD, but may be produced by abnormal coronary flow even with normal coronary arteries. Therapy of underlying AS is the main consideration. Combined valve and coronary artery interventions are safe.

Presented at the 22nd Annual Meeting of the International Society of Cardiovascular Pharmacotherapy (ISCP), 24th-25th August 2017. Barcelona, Spain.