A heart murmur is one of the few things a doctor can find in about ten seconds with a stethoscope. What happens next is usually a version of the same sentence: it is probably nothing, we will keep an eye on it. For decades that was sound advice. Aortic stenosis, the slow narrowing of the valve between the heart and the body’s main artery, was treated as a condition you watched until it declared itself, because the operation to fix it was a serious undertaking and the risks of waiting were thought to be modest.
In 2025 that changed. The European Society of Cardiology and the European Association for Cardio-Thoracic Surgery published new guidelines on valve disease that moved the goalposts in two directions at once, and one line in those guidelines reads as though it were written specifically for a health service like Ireland’s.
TL;DR
- Severe aortic stenosis affects roughly 3 to 4 per cent of people aged 75 and over, which on current CSO population figures means somewhere between 12,000 and 16,000 people in Ireland, about three-quarters of whom have symptoms.
- The 2025 European guidelines lowered the age at which a keyhole valve (TAVI) becomes the recommended option from 75 to 70, and for the first time say intervention should be considered in people with severe stenosis who have no symptoms at all.
- The guidelines explicitly name long waiting lists as a reason to intervene earlier, because a watch-and-wait plan only works if treatment is available quickly once symptoms arrive.
- In Ireland, 45,803 adults were waiting for a first cardiology outpatient appointment at the end of August 2026, 2,166 of them for more than 18 months.
- Practical steps: ask for the numbers from your echocardiogram, keep track of what you have quietly stopped doing, ask about an exercise test, and treat blackouts as urgent rather than embarrassing.
What the valve actually does, and what goes wrong
The aortic valve is a set of three thin flaps that open every time the heart contracts and snap shut the instant it relaxes. Over seven or eight decades, calcium gradually builds up on those flaps and they stiffen. The opening narrows, and the heart muscle has to generate more and more pressure to push the same volume of blood through a smaller gap. For years it manages. Then it stops managing.
Doctors call the narrowing severe when the blood is being forced through at 4 metres per second or faster, when the average pressure difference across the valve reaches 40 mmHg, or when the valve opening has shrunk to 1 square centimetre or less. Those three numbers appear on every echocardiogram report, and they are worth knowing, because they are the numbers your treatment decisions are built on. (For the wider picture of how valves fail, including leaking valves, see our guide to heart valve disease after 50.)
When HIQA assessed this in its health technology assessment, it put the prevalence of severe aortic stenosis at 3 to 4 per cent of adults aged 75 and over, with about three in four of those people having symptoms. The CSO estimated 402,004 people aged 75 and over living in Ireland in April 2026. Apply the prevalence to the population and you get somewhere in the region of 12,000 to 16,000 people with a severely narrowed aortic valve, perhaps 9,000 to 12,000 of them already feeling it.
The symptoms arrive late, and they arrive in disguise
There are three classic symptoms: breathlessness on exertion, chest tightness on exertion, and dizziness or blacking out on exertion. The word doing the heavy lifting there is exertion, and that is precisely the problem.
People in their seventies and eighties rarely wake up one morning gasping. What happens instead is a quiet series of adjustments. The hill on the way back from the shop gets walked in two halves. The lift gets used instead of the stairs. The weekly shop becomes two smaller trips. Gardening happens sitting down. Each adjustment is sensible on its own, and together they can keep a person technically symptom-free for a year or more, not because the valve is coping but because the demands on it have been quietly reduced.
This matters enormously, because almost every decision in valve disease keys off a single question: are you symptomatic? If the honest answer is “I don’t get breathless, but I stopped doing the things that made me breathless”, that is not the same as no symptoms. It is worth saying out loud in the consulting room.
The guidelines offer a way to settle it. In people with severe stenosis who report no symptoms, an exercise test is recommended for risk assessment: it can unmask breathlessness the person has stopped noticing, and it can reveal a drop in blood pressure of more than 20 mmHg during exercise, which is a warning sign in its own right. If you have been told your valve is severely narrowed and that you have no symptoms, asking whether an exercise test is appropriate is a reasonable question.
What the 2025 guidelines changed
Two things, both significant.
First, the age threshold for the keyhole procedure moved. Transcatheter aortic valve implantation (TAVI) threads a replacement valve up through an artery in the groin rather than opening the chest. The 2021 guidelines reserved it for people aged 75 and over, or those at high surgical risk. The 2025 guidelines recommend it as the primary option for anyone aged 70 or over with a standard three-flap valve and suitable anatomy, with conventional surgery remaining the preferred route under 70 where surgical risk is low.
Second, and more striking, the guidelines now say that intervention should be considered in people with severe, high-gradient stenosis who have no symptoms (confirmed by a normal exercise test where feasible) and whose heart is still pumping normally, as an alternative to close monitoring, provided the procedure itself is low risk. That is a genuine break with the watch-and-wait tradition.
The evidence behind it is not uniform, and it is worth being honest about that. The EARLY TAVR trial randomised 901 people with severe but symptom-free stenosis to early TAVI or clinical surveillance, and found a 50 per cent reduction in the combined rate of death, stroke and unplanned cardiovascular hospital admission. But the EVoLVeD trial, which took 224 people with severe stenosis and scarring visible on cardiac MRI, found no reduction in death or unplanned admissions from intervening early. The guidelines reflect that mixed picture: this is a “should be considered” recommendation to be weighed by a heart team with the patient, not an instruction to operate on everyone.
For people who do continue with monitoring, the guidelines are specific about the interval. Someone with severe stenosis and no symptoms should be reviewed at least every six months, and promptly if symptoms appear. Not annually. Not whenever the next letter arrives.
The line in the guidelines that matters most in Ireland
Buried in the section on timing is a sentence that deserves more attention than it has had. The guidelines list long waiting lists, which “preclude prompt treatment when symptoms develop”, as an argument in favour of intervening early.
That is a remarkable thing for a clinical guideline to say. It means the right decision for an individual patient depends in part on how quickly their health service can actually act. Watchful waiting is a strategy that assumes someone is watching, and that when the watching turns up a problem, something happens quickly.
Ireland’s own figures are worth putting beside it. At the end of August 2026, according to National Treatment Purchase Fund data, 45,803 adults were waiting for a first outpatient appointment with a cardiologist. Of those, 19,151 had been waiting more than six months and 2,166 more than 18 months. A further 5,972 adults were waiting for a cardiology inpatient or day-case procedure, and 805 for cardiothoracic surgery, 158 of them for more than a year.
The National Review of Adult Specialist Cardiac Services, chaired by Professor Philip Nolan and published on 8 April 2025, made 23 recommendations aimed squarely at this. It proposed concentrating structural heart interventions, TAVI included, in four national comprehensive cardiac centres: the Mater, St James’s, Cork University Hospital and Galway University Hospital. It also set out something more immediately useful to anyone reading this: an expansion of echocardiography services, including community echo and GP access to echo, with a target of three months from referral to report for routine scans and one month for urgent ones.
Those targets are not yet reality everywhere, but they are now written down, which makes them something you can ask about by name.
None of this is a criticism of the treatment itself. A registry from St James’s Hospital covering 230 TAVI procedures found that the typical patient was 81, that the median hospital stay fell from nine days in 2019 to three days in 2021, and that among patients with 30-day follow-up there were no procedural or 30-day deaths. The procedure works, and it works well in Irish hands. The pinch point is everything that happens before it.
What to do with this
Get your numbers. If you have had an echocardiogram, ask for the peak velocity, the mean gradient, the valve area and the ejection fraction, and write them down. Bring that note to every appointment. Our guide to scans and tests after 50 covers what to expect from the scan itself.
Track what you have stopped doing. A short list, dated, of activities you have dropped or halved in the past year is more useful to a cardiologist than “I’m grand, just slowing down a bit”.
Ask when your next review is due. If your stenosis is severe and you are being monitored, the standard is at least every six months. If your next appointment is further away than that, say so and ask whether it should be brought forward.
Ask whether your case has gone to a heart team. Decisions about surgery versus TAVI are meant to be made by a multidisciplinary team, not a single clinician, and you are entitled to know whether that discussion has happened.
Use your GP. Everyone aged 70 and over in Ireland qualifies for a GP visit card with no means test, regardless of income. You can register online or ring 0818 22 44 78 for a paper form. A GP is the person who refers you for the echo and who can mark a referral urgent.
Ring the Irish Heart Foundation if you want to talk it through. Their Nurse Support Line is on 01 668 5001, open 9am to 5pm on Mondays and 9am to 1pm Tuesday to Friday.
When not to wait
Some things should not go on a waiting list at all. Contact your GP the same day, or go to an emergency department, if you have:
- a blackout or near-blackout, particularly during or just after exertion
- chest pain or tightness that comes on at rest
- breathlessness at rest, or breathlessness that wakes you or forces you to sleep propped up
- a clear worsening over days rather than months
Chest pain with sweating, nausea or collapse is a 112 or 999 call, not a GP appointment. And if you have blacked out, there are driving rules that apply, which we cover in our guide to fainting and blackouts after 50.
The honest summary
Aortic stenosis is one of the few conditions of later life where the ending is genuinely changeable. Untreated, severe symptomatic stenosis carries a mortality that HIQA put at around 40 per cent within five years. Treated, most people are home within days and back to doing the things they had quietly given up.
What changed in 2025 is the recognition that the gap between those two outcomes is partly a matter of timing, and that timing is partly a matter of systems. The guidelines have done their part by saying so. The rest is a matter of knowing your numbers, naming your symptoms accurately, and being the kind of patient who asks when the next review is due.
At Críonna Health we write about ageing as something to be navigated well rather than endured, and this is a good example of why the detail matters: the difference between “we’ll keep an eye on it” and “we’ll review you in six months and here’s what to ring about” is not medical jargon. It is the difference between a plan and a hope.
This article is for general information and is not a substitute for individual medical advice. If you have concerns about your heart, speak to your GP.
📷 Photo by Tolga Ahmetler on Unsplash
