Aortic Stenosis

Question 1

What is aortic stenosis?

Answer 1

Narrowing of the left ventricular outflow at the level of the aortic valve

Question 2

What are the 3 causes of aortic stenosis?

Answer 2

1 - stenosis secondary to rheumatic heart disease (commonest)

2 - calcification of a congenital bicuspid aortic valve

3 - calcification/degeneration of a tricuspid aortic valve in the elderly

Question 3

Epidemiology summary of aortic stenosis? (3)

Answer 3

• ~3% of 75 y/o
• affects males more than females
• those with bicuspid aortic valves may present earlier

Question 4

Presentation of aortic stenosis?

Answer 4

May be asymptomatic initially

• angina (due to increased O2 demand of hypertrophied ventricles)
• syncope/dizziness on exercise
• symptoms of heart failure

Question 5

Examination findings in aortic stenosis?

Answer 5

BP - narrow pulse pressure
Pulse - slow-rising
Palpation - thrill in aortic area, forceful sustained thrusting UNdisplaced apex beat
Auscultation - harsh ejection systolic murmur at aortic area, may radiate to carotid artery + apex

Question 6

BP sign of aortic stenosis on examination?

Answer 6

Narrow pulse pressure

Question 7

Pulse sign of aortic stenosis (and regurgitation) on examination?

Answer 7

Slow-rising pulse

• pulsus tardus - slow-rising/falling = stenosis
• pulsus celer - fast-rising/falling = regurgitation

Question 8

Palpation signs of aortic stenosis on examination?

Answer 8

• thrill in aortic area (if severe)

- forceful sustained thrusting undisplaced apex beat

Question 9

Auscultation signs of aortic stenosis on examination?

Answer 9

Harsh ejection systolic murmur at aortic area
- may radiate to carotid artery and apex

Second heart sound may be softened/absent (due to calcification)

Question 10

What sound might a bicuspid aortic valve produce on auscultation?

Answer 10

An ejection click

Question 11

Investigations indicated in aortic stenosis?

Answer 11

ECG
CXR
Echocardiogram
Cardiac angiography

Question 12

Signs of aortic stenosis on ECG?

Answer 12

• Signs of left ventricular hypertrophy (deep S wave V1-2, tall R wave V5-6, inverted T wave I/V5-6/aVL, left axis deviation)
• LBBB

Question 13

Signs of aortic stenosis on CXR?

Answer 13

• Post-stenotic enlargement of the ascending aorta

- Calcification of aortic valve

Question 14

Use of echocardiogram in aortic stenosis?

Answer 14

• visualises structural changes of the valves and level of stenosis
• estimates aortic valve area and pressure gradient across the valve in systole
• assesses left ventricular function

Question 15

3 levels of valve stenosis?

Answer 15

Valvar, supravalvar, subvalvar

Question 16

Use of cardiac angiography in aortic stenosis?

Answer 16

• allows differentiation from other causes of angina
• assesses for concomitant coronary artery disease (50% of severe aortic stenosis cases also have significant coronary artery disease)