6.2 MTB Step 3 - Valvular Heart Disease (Aortic Stenosis) Flashcards

1
Q

AORTIC STENOSIS (AS)

What are (5) Common Clinical Presentations of AS?

A
  1. Older Patient w/ hx of HTN
  2. CHEST PAIN (most common)
  3. CAD (in upto 50% of patients)
  4. Syncope
  5. CHF
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2
Q

AORTIC STENOSIS (AS)

What is the Prognosis in the following (3) types of patients with AS?

  1. AS + CAD
  2. AS + Syncope
  3. AS + CHF
A
  1. AS + CAD = 3 - 5 year average survival
  2. AS + Syncope = 2 - 3 year average survival
  3. AS + CHF = 1.5 - 2 year average survival
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3
Q

AORTIC STENOSIS (AS)

What is the Mechanism of Syncope/Angina in AS?

A

A stiff valve just proximal to the entry point of coronaries blocks blood flow into the vertebral and basilar arteries and carotids:

  • No Flow to Brain = Passing out.
  • Thus, AS causes LV Hypertrophy.
  • LV Hypertrophy = Increased Demand
  • AS = Blocked Flow with Increased Demand = Chest Pain
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4
Q

AORTIC STENOSIS (AS)

What Type of Murmur does AS give?

A

Crescendo-Decrescendo Systolic Murmur

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5
Q

AORTIC STENOSIS (AS)

What is the Mechanism of Crescendo/Decrescendo Murmur of AS?

A

The first part of the Cardiac Cycle is Isovolumetric contraction:

  • With Isovolumetric contraction, no blood moves.
  • No blood moving = No murmur.
  • Peak flow occurs in Mid-Systole.
  • Peak Flow = Peak Noise.
  • Hence, AS yields a Diamond-shaped Crescendo-Decrescendo murmur.
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6
Q

AORTIC STENOSIS (AS)

  1. What is the Best INITIAL Test for AS?
  2. What is a MORE Accurate Test for AS?
  3. What is the Most ACCURATE Test for AS?
A
  1. TTE
  2. TEE
  3. Left Heart Catheterization - also allows the most accurate method of assessing the Pressure Gradient across the Aortic Valve (normal aortic valve gradient = 0).
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7
Q

AORTIC STENOSIS (AS)

  1. What is considered Mild AS?
  2. What is considered Moderate AS?
  3. What is considered Severe AS?
A

Left Heart Catheterization:

  1. Mild AS = gradient < 30 mmHg
  2. Moderate AS = gradient 30 - 70 mmHg
  3. Severe AS = gradient > 70 mmHg
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8
Q

AORTIC STENOSIS (AS)

What is the Best INITIAL Therapy for AS?

A

Diuretics

  • However, they will NOT alter Long-term prognosis
  • Further, overdiuresis is Dangerous, and use of diuretics needs to be VERY judicious.
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9
Q

AORTIC STENOSIS (AS)

What is the Most Common definitive Treatment for AS?

A

Valve Replacement Surgery:

  • Bioprosthetic Valves (porcine, bovine) last 10 years on average, but do NOT require anticoagulation with Warfarin.
  • Mechanical Valves last 15 - 20 years on average, but MUST be treated with Warfarin to an INR = 2 - 3.

Valve replacement is well tolerated, even in the elderly.

Answer for “Which procedure has a Higher Risk of AKI and A-Fib?” = SURGERY

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10
Q

AORTIC STENOSIS (AS)

What is considered an Acceptable Alternative to the Most Common definitive Treatment for AS?

A

Transcatheter Aortic Valve Replacement (TAVR)

  • Valve Replacement deployed through a catheter.
  • Slightly lower risk of death compared with surgery.
  • NOT an option for Regurgitant Lesions (i.e., AR, MR)
  • Answer* *for “Which procedure has a Higher Risk of Residual Aortic Regurgitation and Need for Pacemaker Placement?” = TAVR
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