Aortic Stenosis

Question 1

…. … refers to obstruction of blood flow across the aortic valve, typically due to calcification.

Answer 1

Aortic stenosis refers to obstruction of blood flow across the aortic valve, typically due to calcification.

Question 2

Aortic stenosis is the most common valvular disease in the Europe and North America. It affects between 2-7% of those over 65 and symptomatic disease affects … four times more frequently than …. Typically a disease of the elderly, presenting in the seventh or eighth decades of life.

Answer 2

Aortic stenosis is the most common valvular disease in the Europe and North America. It affects between 2-7% of those over 65 and symptomatic disease affects men four times more frequently than women. Typically a disease of the elderly, presenting in the seventh or eighth decades of life.

Question 3

… is the most common cause of aortic stenosis in the western world.

Answer 3

Calcification is the most common cause of aortic stenosis in the western world.

Question 4

Risk factors for calcification (degenerative) aortic stenosis:

Answer 4

Risk factors: hypercholesterolaemia, hypertension, smoking and diabetes.

Question 5

The most common congenital abnormality of the heart occurring with a frequency of 1-2%, with males more commonly affected - what is it?

Answer 5

aortic stenosis - Bicuspid valve (congenital)

Question 6

Aortic stenosis - Bicuspid valve (congenital)

Answer 6

Valves predisposed to becoming stenotic.
Stenosis tends to appear at a younger age (<65).
Abnormal valve leads to turbulent flow with subsequent fibrosis and calcification.

Question 7

Rheumatic heart disease

Answer 7

An autoimmune condition that follows streptococcal (Group A) infection.

Question 8

Aortic stenosis places pressure on the left ventricle; in response it undergoes …

Answer 8

Aortic stenosis places pressure on the left ventricle; in response it undergoes hypertrophy.

Question 9

Aortic stenosis places pressure on the … ventricle; in response it undergoes hypertrophy.

Answer 9

Aortic stenosis places pressure on the left ventricle; in response it undergoes hypertrophy.

Question 10

Aortic stenosis is a problem of left ventricular outflow. A pressure gradient develops across the valve (hence, an … … murmur may be heard).

Answer 10

Aortic stenosis is a problem of left ventricular outflow. A pressure gradient develops across the valve (hence, an ejection systolic murmur may be heard).

Question 11

Angina may develop for a number of reasons in aortic stenosis (3)

Answer 11

Reduced coronary flow
Increased oxygen requirements (from hypertrophied cardiac muscle)
Concomitant coronary artery disease

Question 12

A classical triad of ‘SAD’ is often described in …

Answer 12

Aortic stenosis

Question 13

A classical triad of ‘SAD’ is often described in aortic stenosis - what is this?

Answer 13

Syncope (exertional)
Angina
Dyspnoea

Question 14

Does everyone with aortic stenosis present with the classical triad ‘SAD’?

Answer 14

The classical triad of ‘SAD’ is only seen in around 40-50% of patients with aortic stenosis

Question 15

Signs of aortic stenosis

Answer 15

Ejection systolic murmur, radiating to the carotids.
Sustained apex
Slow rising pulse
Narrow pulse pressure
Others:
- Soft S2 - a marker of severity, the aortic component of the second heart sound may become quieter in more severe disease as the valve leaflets fail to oppose each other forcefully.
- Fourth heart sound (S4) - caused by the atria contracting against stiff, hypertrophied ventricles.
- Reversed splitting

Question 16

Ejection systolic murmur, radiating to the carotids.
Sustained apex
Slow rising pulse
Narrow pulse pressure
Others:
Soft S2 - a marker of severity, the aortic component of the second heart sound may become quieter in more severe disease as the valve leaflets fail to oppose each other forcefully.
Fourth heart sound (S4) - caused by the atria contracting against stiff, hypertrophied ventricles.
Reversed splitting

All signs of …

Answer 16

Aortic stenosis

Question 17

These are the signs and symptoms of …

Answer 17

Aortic stenosis

Question 18

… is used to diagnose aortic stenosis.

Answer 18

Echocardiogram is used to diagnose aortic stenosis.

Question 19

Bedside investigations for aortic stenosis:

Answer 19

Observations
Blood pressure
ECG
Left ventricular hypertrophy (deep S-waves in V1 and V2, tall R-waves in V5 and V6).
Left ventricular strain may be seen in severe disease

Question 20

Bloods for aortic stenosis investigation:

Answer 20

FBC
U&Es
Cholesterol
Clotting

Question 21

Imaging for aortic stenosis:

Answer 21

CXR
​Typically demonstrates a small heart; cardiomegaly occurs if heart failure develops.
Dilated ascending aorta.
Echocardiogram
​Allows assessment of the valve area, ejection fraction and ventricular hypertrophy.
Aortic stenosis is classified by severity on echocardiogram according to its transaortic pressure gradient & valve area.

Question 22

CXR of a patient with … typically is as follows:

Typically demonstrates a small heart; cardiomegaly occurs if heart failure develops.
Dilated ascending aorta.

Answer 22

aortic stenosis

Question 23

Aortic stenosis is classified by severity on echocardiogram according to its transaortic … … & … area.

Answer 23

Aortic stenosis is classified by severity on echocardiogram according to its transaortic pressure gradient & valve area.

Question 24

Aortic stenosis is classified by severity on echocardiogram according to its … pressure gradient & valve area.

Answer 24

Question 25

Special tests for aortic stenosis:

Answer 25

Cardiac MRI​
Cardiac catheterisation
ECG exercise stress testing
May be used in asymptomatic patients. A positive test may be indicated by the onset of symptoms, ECG changes, or an abnormal BP response.

Question 26

Management of aortic stenosis:

Answer 26

Surgical aortic valve replacement is indicated in severe or symptomatic disease. Severity is indicated on echo by LVH, pressure gradient and valve area. Successful surgery leads to much improved quality of life.

Question 27

Aortic stenosis management - Stenotic lesions may be treated with a …, a procedure in which the stenotic valve leaflets are forced apart, it may be:

Percutaneous balloon …
Open ….

Answer 27

Stenotic lesions may be treated with a valvotomy, a procedure in which the stenotic valve leaflets are forced apart, it may be:

Percutaneous balloon valvotomy
Open valvotomy

Question 28

… valve - require long-term anticoagulation, long lifespan reducing the need for a second operation. Suited to younger patients.

Answer 28

Mechanical valve - require long-term anticoagulation, long lifespan reducing the need for a second operation. Suited to younger patients.

Question 29

… valve - no need for long-term anticoagulation, limited life span (around 10 years) and a repeat operation is more likely. Suited to older patients.

Answer 29

Bioprosthetic valve - no need for long-term anticoagulation, limited life span (around 10 years) and a repeat operation is more likely. Suited to older patients.

Question 30

Valve replacement - compare mechanical and bioprosthetic valves (age, management, lifespan)

Answer 30

Mechanical valve - require long-term anticoagulation, long lifespan reducing the need for a second operation. Suited to younger patients.
Bioprosthetic valve - no need for long-term anticoagulation, limited life span (around 10 years) and a repeat operation is more likely. Suited to older patients.

Question 31

The decision of mechanical vs bioprosthetic valve should take into account patient-specific factors and wishes. Traditionally valve replacement has necessitated open surgery, novel techniques now allow … replacement: transcatheter aortic valve replacement (TAVR) - a … invasive technique that utilises an expandable valve, may be used in patients who are not candidates for open surgery.

Answer 31

The decision of mechanical vs bioprosthetic valve should take into account patient-specific factors and wishes. Traditionally valve replacement has necessitated open surgery, novel techniques now allow percutaneous replacement: transcatheter aortic valve replacement (TAVR) - a minimally invasive technique that utilises an expandable valve, may be used in patients who are not candidates for open surgery.

Question 32

In patients having open surgery for aortic stenosis, Coronary angiogram may be used to demonstrate atherosclerotic disease that may be treated with … at the same time as the open surgery.

Answer 32

In patients having open surgery for aortic stenosis, Coronary angiogram may be used to demonstrate atherosclerotic disease that may be treated with CABG at the same time as the open surgery.

Question 33

S1 and S2:

The first heart sound (S1) is caused by the … of the atrioventricular valves (the tricuspid and mitral valves) at the start of the systolic contraction of the ventricles.

The second heart sound (S2) is caused by the … of the semilunar valves (the pulmonary and aortic valves) once the systolic contraction is complete.

Answer 33

The first heart sound (S1) is caused by the closing of the atrioventricular valves (the tricuspid and mitral valves) at the start of the systolic contraction of the ventricles.

The second heart sound (S2) is caused by the closing of the semilunar valves (the pulmonary and aortic valves) once the systolic contraction is complete.

Question 34

The first heart sound (S1) is caused by the closing of the …. valves (the tricuspid and mitral valves) at the start of the systolic contraction of the ventricles.

The second heart sound (S2) is caused by the closing of the … valves (the pulmonary and aortic valves) once the systolic contraction is complete.

Answer 34

The first heart sound (S1) is caused by the closing of the atrioventricular valves (the tricuspid and mitral valves) at the start of the systolic contraction of the ventricles.

The second heart sound (S2) is caused by the closing of the semilunar valves (the pulmonary and aortic valves) once the systolic contraction is complete.

Question 35

3rd Heart Sound (S3) - when is it normal?

Answer 35

This can be normal in young (15-40 years) healthy people because the heart functions so well that the ventricles easily allow rapid filling. In older patients it can indicated heart failure, as the ventricles and chordae are stiff and weak so they reach their limit much faster than normal. Picture this like tight hamstrings in an old de-conditioned patient sharply tightening as they start to bend over.

Question 36

4th Heart Sound (S4) - is this normal?

Answer 36

A fourth heart sound (S4) is heard directly before S1. This is always abnormal and relatively rare to hear. It indicates a stiff or hypertrophic ventricle and is caused by turbulent flow from an atria contracting against a non-compliant ventricle.

Question 37

4 valve areas -

…: 2nd I.C.S left sternal border
…: 2nd I.C.S right sternal border
…: 5th I.C.S left sternal border
…: 5th I.C.S mid clavicular line (apex area)

Answer 37

Pulmonary: 2nd I.C.S left sternal border
Aortic: 2nd I.C.S right sternal border
Tricuspid: 5th I.C.S left sternal border
Mitral: 5th I.C.S mid clavicular line (apex area)

Question 38

Listen to “… point”. This is in the third intercostal space on the left sternal border and is the best area for listening to heart sounds (S1 and S2).

Answer 38

Listen to “Erb’s point”. This is in the third intercostal space on the left sternal border and is the best area for listening to heart sounds (S1 and S2).

Question 39

Special manoeuvres can be used to emphasise certain murmurs:

Patient on their left hand side (… …
Patient sat up, learning forward and holding exhalation (aortic regurgitation)

Answer 39

Patient on their left hand side (mitral stenosis)

Patient sat up, learning forward and holding exhalation (aortic regurgitation)

Question 40

Special manoeuvres can be used to emphasise certain murmurs:

Patient on their left hand side (mitral stenosis)
Patient sat up, learning forward and holding exhalation (… …

Answer 40

Patient on their left hand side (mitral stenosis)

Patient sat up, learning forward and holding exhalation (aortic regurgitation)

Question 41

Assessing a Murmur (SCRIPT mnemonic)

Answer 41

S – Site: where is the murmur loudest?
C – Character: soft / blowing / crescendo (getting louder) / decrescendo (getting quieter) / crescendo-decrescendo (louder then quieter)
R – Radiation: can you hear the murmur over the carotids (AS) or left axilla (MR)?
I – Intensity: what grade is the murmur?
P – Pitch: is it high pitched or low and grumbling? Pitch indicates velocity.
T – Timing: is it systolic or diastolic?

Question 42

Grading a murmur is quite subjective but is helpful is assessing the severity of the defect and will make you sound clever. If in doubt it is probably grade 2 or 3.

Answer 42

Difficult to hear
Quiet
Easy to hear
Easy to hear with a palpable thrill
Can hear with stethoscope barely touching chest
Can hear with stethoscope off the chest

Question 43

… stenosis causes left atrial hypertrophy.

Answer 43

Mitral stenosis causes left atrial hypertrophy.

Question 44

… stenosis causes left ventricular hypertrophy.

Answer 44

Aortic stenosis causes left ventricular hypertrophy.

Question 45

… regurgitation causes left atrial dilatation.

Answer 45

Mitral regurgitation causes left atrial dilatation.

Question 46

… regurgitation causes left ventricular dilatation.

Answer 46

Aortic regurgitation causes left ventricular dilatation.

Question 47

Mitral Stenosis - caused by … (2)

Answer 47

It is caused by:

Rheumatic Heart Disease
Infective Endocarditis

Question 48

A 67-year-old female is seen by the GP with a one-year history of breathlessness on exertion. She also complains of dizzy spells and had one episode where she lost consciousness. On examination, she has a slow-rising pulse and an ejection systolic murmur is noted with radiation to the carotids.

What is the most likely diagnosis?

A	Aortic regurgitation
B     Aortic stenosis
C	Pulmonary stenosis
D	Mitral regurgitation
E	Mitral stenosis

Answer 48

This women is suffering from aortic stenosis. The classical symptoms of aortic stenosis are syncope, angina and dyspnoea (SAD).
The typical examination findings are a slow-rising pulse, narrow pulse pressure and ejection systolic murmur that radiates to the carotids. Patients with a congenital bicuspid aortic valve, which occurs in approximately 1% of the population, will present earlier. The definitive management of aortic stenosis is surgical replacement / repair. Surgery is usually considered once symptoms have developed because of the increased risk of sudden death.

Question 49

Which of the following statements is correct regarding aortic stenosis?

A It causes a pansystolic murmur loudest in the aortic region
B A valve area < 1 cm2 is considered severe aortic stenosis
C A collapsing pulse can be found on examination
D It occurs at an older age in patients with a congenital bicuspid valve
E A pressure gradient > 70mmHg is considered mild aortic stenosis

Answer 49

The severity of aortic stenosis can be graded by assessing the mean pressure gradient and the aortic valve area on echocardiography.
Aortic stenosis is a common cardiac murmur that usually presents with an ejection systolic murmur which radiates to the carotids. It can cause a slow-rising pulse and narrow pulse pressure with classical symptoms of syncope, angina and dyspnoea. It usually occurs secondary to calcification and narrowing of the aortic valve area. This may occur at a younger age in patients with a congenitally bicuspid valve.

Question 50

What is the most common cause of mitral stenosis?

A	Carcinoid syndrome
B	Turner syndrome
C	Mitral annular calcification
D	Congenital MS
E	Rheumatic fever

Answer 50

Mitral stenosis most commonly results from rheumatic heart disease.
Acute rheumatic fever is a non-suppurative complication of infection by group A Streptococcus (GAS) pharyngitis (‘strep throat’). Though increasingly uncommon in the western world due to wide-spread antibiotic use, it is still a significant cause of illness in the developing world.

It is thought to result from ‘molecular mimicry’ - this refers to cross-reactivity of antibodies produced to combat the GAS with normal tissues. This can result in symptoms like arthritis and carditis. The atrial and mitral valves are most commonly affected - with a small proportion of patients developing acute mitral or atrial insufficiency. Most recover from the acute episode but can go on to develop progressive valvular disease that may not present symptomatically for many years. This chronic phase most commonly affects the mitral valve, with the aortic and tricuspid less frequently involved (the pulmonary valve is rarely affected). In the chronic phase stenosis, regurgitation or a mixed picture can be seen.

Question 51

Which of the following statements is false regarding the management of heart failure?

A Carvedilol is useful in the management of heart failure
B ACE-inhibitors should be used as first line therapy
C Furosemide is used for symptomatic relief in heart failure
D Digoxin can be initiated as first-line therapy for heart failure
E Spironolactone shows prognostic benefit in patients with severe heart failure

Answer 51

Digoxin is used if there is worsening of severe heart failure despite use of first line (e.g. ACE-i / beta-blocker) and second line (e.g. ARB / spironolactone) agents.

Question 52

Baroreceptors are able to detect changes in arterial stretch upon standing to help maintain cerebral perfusion.

What is the location of the main baroreceptors?

A	Carotid bodies
B	Left atrial appendage
C	Carotid sinus
D	Ascending aorta
E	Interventricular septum

Answer 52

The most important arterial baroreceptors are located in the aortic arch and carotid sinus (bifurcation of external and internal carotid arteries around vertebral level C4).
Baroreceptors respond to stretching of the arterial wall. If arterial pressure suddenly falls upon standing, the stretch on the walls is decreased. This results in a decreased frequency of action potentials within neurones to the brainstem. This is detected as a fall in blood pressure.

Carotid sinus baroreceptors are innervated by a branch of the glossopharyngeal nerve. Aortic arch baroreceptors are innervated by the aortic nerve (a branch of the vagus nerve). Both nerves synapse in the nucleus tractus solitarius (NTS) located in the medulla of the brainstem. From here, both branches of the autonomic nervous system may be stimulated to help increase or decrease blood pressure accordingly.

Question 53

Which of the following is a feature of severe aortic stenosis?

A	Ejection systolic murmur
B	Murmur radiates to the carotids
C     Soft S2 heart sound
D	Displaced apex beat
E	Diastolic murmur

Answer 53

Aortic stenosis is a common valvular pathology affecting 2-7% over the age of 65.

• Narrow pulse pressure
• Slow-rising pulse
• Quiet/absent S2
• Audible S4
• Palpable thrill & heaving apex
• Congestive cardiac failure