A Review of Sex Differences in Patients with Aortic Stenosis: A Focus on Diagnostic and Treatment Differences, a Narrative Review

Severe aortic stenosis represents a growing burden of disease globally with a high risk of death if untreated. There are sex differences in the pathophysiological disease process affecting the aortic valve, patients’ clinical presentation, progression of valve disease, ventricular adaptation, timing of symptom onset, delays in diagnosis, and treatment strategies. Female patients are more likely than male patients to have preserved left ventricular function with concentric left ventricular hypertrophy and smaller left ventricular cavity sizes, which consequently produce low stroke volumes and more paradoxical low flow low gradient severe aortic stenosis. These differences can lead to diagnostic uncertainty resulting in delays to treatment and associated morbidity and mortality. The higher mortality rate reported in women in observational cohorts is multifactorial. It is influenced by delayed diagnosis, lower referral rates, older age at intervention and frailty; rather than female sex alone. There exist variations in the treatment and management of aortic stenosis with women being underdiagnosed and conservatively managed compared to men. A better understanding of the differences in pathophysiology, ventricular adaptation and haemodynamic effects between the sexes are key to improving diagnostic accuracy and referral for timely intervention. Women may require a more tailored approach to their lifetime management of aortic stenosis due to their smaller anatomy and greater comorbidity burden at presentation. This narrative review explores the epidemiology, pathophysiology, presentation, diagnosis and management of aortic stenosis in female patients.