Aortic Stenosis

Question 1

Epidemiology

Answer 1

Aortic stenosis is a major cause of CHF in elderly patients

Question 2

Causes

Answer 2

Mechanical wear and tear: primary cause in adults
Unicuspid or bicuspid defects leading to stenosis: common in pediatric patients, associated with turners syndrome (xo)
Rheumatic fever: though more often the mitral valve is damaged in RF

Question 3

Symptoms

Answer 3

Asymptomatic until very advanced disease
Dyspnea
Angina
HF: once symptoms begin they progress rapidly to death unless treated

Question 4

Physical Exam

Answer 4

Crescendo-decrescendo murmur
Peaks in early systole
Radiates to the carotids
Right upper sternal border (classically) OR left upper sternal border (in some patients)

Parodoxically split S2
Occurs during exhalation (not inhalation)

Severe stenosis results in
A late-peaking murmur
Diminished A2 component of the 20nd heart sound
Pulsus parvus et tardus

Question 5

Evaluation

Answer 5

Echocardiography is diagnostic gold standard AND shows
Thick, calcified aortic valve possibly unicuspid or bicuspid anatomy

EKG is usually normal until disease is severe
Characteristic findings include
Ventricular hypertrophy
Increased voltage in limb leads
Left axis deviation

Question 6

Differential

Answer 6

Includes other valvular disorders and other causes of CHF

Question 7

Differentials (Systolic Murmurs)

Answer 7

Hypertrophic Obstructive
Cardiomyopathy
Midsystolic crescendo-decrescendo murmur heard best at lower left sternal border and apex
Asymmetric Septal Hypertropy
Can radiate to the carotids

Mitral Regurgitation
Holosystolic murmur at the
apex radiating to the axilla

Tricuspid Regurgitation
Soft holosystolic at left sternal
border

Mitral Prolapse
Apical midsystolic click and a
delayed or a late systolic
murmur.

Question 8

Differentials (Diastolic Murmurs)

Answer 8

Aortic regurgitation
High pitched blowing early
diastolic decrescendo murmur
at left sternal border, murmur heard at 3rd/4th interspace when patient leading forward holding full
expiration

Mitral stenosis
Accentuated S1
Diastolic rumble after an opening snap
As murmur worsens, snap is
heard closer to S2

Question 9

Treatment

Answer 9

Balloon valvuloplasty: indicated as temporizing measure before valve replacement

Aortic valve replacement: indicated in advanced aortic stenosis as definitive treatment

Question 10

Prognosis, Prevention, and Complications

Answer 10

Advanced aortic stenosis requires intervention for survival

Patients at increased risk of
Arrhythmias
Endocarditis
Left-sided failure
LVH

Question 11

High Yield

Answer 11

Presentation
Elderly man with a history of HTN presents with chest pain and a systolic crescendo-decrescendo murmur heard by the right upper sternal border that
radiates to the carotids

The murmur is louder with leg raise, squat, and amyl nitrate
The murmur is quieter with standing and handgrip

Management
Best initial test: transthoracic echocardiogram
More accurate test: transesophageal echocardiogram
Most accurate test: left heart catheterization
Best initial therapy: diuretics (overdiuresis can be very dangerous)
Definitive therapy: valve replacement
CCS tests: also order EKG and chest radiograph