Evaluation and Management of Aortic Stenosis and Carotid Artery Disease

Initial Clinical Assessment

The American Heart Association recommends that older adults presenting with chest pain, syncope, or shortness of breath should be evaluated first with echocardiography to rule out aortic stenosis, as these are classic symptoms of severe AS requiring urgent assessment 1, 2
The American College of Cardiology suggests listening for a loud, late-peaking systolic murmur radiating to the carotids, which confirms severe aortic stenosis 1, 2
Assessing for a single or paradoxically split second heart sound (S2) is highly specific for severe AS 1, 2
The only reliable physical finding that excludes severe AS is a normally split second heart sound 1, 2

The European Society of Cardiology recommends transthoracic echocardiography as the first-line test when AS is suspected based on symptoms or murmur 1, 2
Severe AS is defined as: aortic jet velocity ≥4 m/s, mean gradient ≥40 mmHg, or valve area ≤1.0 cm² 1, 2
The American Heart Association suggests using duplex ultrasound as first-line imaging to diagnose internal carotid artery stenosis 3, 4

Symptomatic severe AS requires urgent intervention—medical therapy alone is inadequate, and surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) should be considered based on surgical risk and anatomy 1, 2
For symptomatic carotid stenosis (50-99%), CEA is recommended if documented 30-day risk of procedural death/stroke is <6% 3, 7, 8
The European Heart Journal recommends dual antiplatelet therapy (aspirin and clopidogrel) for at least 21 days in symptomatic carotid stenosis patients not undergoing revascularization 3, 7

All patients require aggressive cardiovascular risk factor modification regardless of intervention decisions, including statins with target LDL-C <1.4 mmol/L (55 mg/dL) or >50% reduction 4, 7
Long-term single antiplatelet therapy (aspirin or clopidogrel) is recommended after carotid revascularization 3, 4, 7, 8

After ICA revascularization, surveillance with duplex ultrasound is recommended within the first month 7, 8
Once-yearly follow-up is recommended to check cardiovascular risk factors and treatment compliance 7, 8