Aortic Stenosis Flashcards
Clinical signs of Aortic Stenosis
- Slow rising, low volume pulse
- Narrow pulse pressure
- Apex beat is sustained in stenosis (HP: heaving pressure‐loaded)
- Thrill in aortic area (right sternal edge, second intercostal space)
-
Auscultation:
- A crescendo-decrescendo, ejection systolic murmur (ESM) loudest in the aortic area during expiration and radiating to the carotids.
- Severity: soft and delayed A2 due to immobile leaflets and prolonged LV emptying, delayed (not loud) ESM, fourth heart sound S4.
Auscultation in Aortic stenosis
A crescendo-decrescendo, ejection systolic murmur (ESM) loudest in the aortic area during expiration and radiating to the carotids.
Severity:
- Soft and delayed A2 due to immobile leaflets and prolonged LV emptying,
- delayed (not loud) ESM,
- fourth heart sound S4
Evidence of complications in Aortic stenosis
1. Endocarditis: Splinters, Osler’s nodes (finger pulp), Janeway lesions (palms), Roth spots (retina), temperature, splenomegaly and haematuria
2. Left ventricular dysfunction: Dyspnoea, displaced apex and bibasal crackles
3. Conduction problems:
- -> acute, endocarditis;
- -> chronic, calcified aortic valve node
Differential diagnosis of Aortic stenosis
1. HOCM
2. VSD
3. Aortic sclerosis: normal pulse character and no radiation of murmur
4. Aortic flow: high output clinical states e.g. pregnancy or anaemia
Causes of Aortic stenosis(AS)
1. Congenital: bicuspid aortic valve
2. Acquired:
- -> Age (senile degeneration and calcification);
- -> Streptococcal (rheumatic)
Associations of Aortic stenosis
ABC
- Angiodysplasia
- Bicuspid aortic valve
- Coarctation
Severity of Aortic stenosis
1. Signs Auscultation features: Soft and delayed A2 due to immobile leaflets and prolonged LV emptying, delayed (not loud) ESM, fourth heart sound S4
2. Mortality risk:
- Angina 50% mortality at 5 years
- Syncope 50% mortality at 3 years
- Breathlessness 50% mortality at 2 years
3. Biventricular failure (right ventricular failure is preterminal)
Investigations in Aortic stenosis
1. ECG: LVH on voltage criteria, conduction defect (prolonged PR interval)
2. CXR: often normal; calcified valve
3. Echo: mean gradient: >40 mm Hg aortic (valve area <1.0 cm2) if severe
4. Catheter: invasive transvalvular gradient and coronary angiography (coronary artery disease often coexists with aortic stenosis)
Management of Aortic Stenosis
- Asymptomatic
⚬⚬ None specific, good dental health
⚬⚬ Regular review: symptoms and echo to assess gradient and LV function
- Symptomatic
A- Surgical
1- Aortic valve replacement +/− CABG
2- Operative mortality 3–5% depending on the patient’s EuroScore (www.euroscore.org/calc.html)
B- Percutaneous
1- Balloon aortic valvuloplasty (BAV)
2- Transcutaneous aortic valve implantation (TAVI)
a- Transfemoral (or transapical and transaortic)
b- Maybe recommended
–> if high surgical risk (logEuroscore >20%) or
–> inoperable cases (number needed to treat to prevent death at 1 year = 5)
Duke’s criteria for infective endocarditis
Major:
1. Typical organism in two blood cultures
2. Echo: abscess^, large vegetation^, dehiscence^
Minor:
1. Pyrexia >38°C
2. Echo suggestive
3. Predisposed, e.g. prosthetic valve
4. Vascular phenomenon, including major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, or Janeway lesions
5. Immunologic/Vasculitic phenomenon such as (ESR↑, CRP↑), glomerulonephritis, Osler nodes, Roth spots, and RF
6. Atypical organism on blood culture
=> Diagnose if the patient has 2 major, 1 major and 2 minor, or 5 minor criteria.
(^ plus heart failure/refractory to antibiotics/heart block are indicators for urgent surgery).
Indications for antibiotic prophylaxis for Infective Endocarditis
Antibiotic prophylaxis is now limited to those with
1- Prosthetic valves,
2- Previous endocarditis,
3- Cardiac transplants with valvulopathy and
4- Certain types of congenital heart disease.
