Aortic stenosis Flashcards
What are 4 clinical features of symptomatic disease?
- Chest pain
- Dyspnoea
- Syncope
- Murmur
What is the murmur characteristic of aortic stenosis?
ejection systolic murmur (ESM)
Where does the ejection systolic murmur typically radiate to?
carotids
What can reduce the ejection systolic murmur of aortic stenosis?
Valsalva manoeuvre
What are 6 signs of aortic stenosis on examination?
- narrow pulse pressure
- slow-rising pulse
- delayed ejection systolic murmur
- soft/absent S2
- S4
- thrill
What is the most common cause of aortic stenosis in patients >65 years?
degenerative calcification
What is the most common cause of aortic stenosis in patients <65 yeras?
bicuspid aortic valve (as opposed to tricuspid)
What are 5 overall causes of aortic stenosis?
- Degenerative calcification
- Bicuspid aortic valve
- William’s syndrome (supravalvular aortic stenosis)
- Post-rheumatic disease
- Subvalvular: hypertrophic obstructive cardiomyopathy (HOCM)
What type of aortic stenosis is caused by William’s syndrome?
supravalvular
What is an example of a cause of subvalvular aortic stenosis?
HOCM (hypertrophic obstructive cardiomyopathy)
What is the management of asymptomatic aortic stenosis?
observe the patient
What is the management of sympomatic aortic stenosis?
valve replacement
What is the management of asymptomatic aortic stenosis when the valvular gradient is >40 mmHg and with features of left-ventricular systolic dysfunction?
consider surgery (despite being asymptomatic)
What should be done prior to surgery for aortic stenosis and why?
angiogram - cardiovascular disease may coexist, may be able to combine procedures
What is the management of patients with critical aortic stenosis who are not fit for valve replacement?
balloon valvuloplasty
What is considered the triad of symptoms of aortic stenosis?
- Dyspnoea
- Angina
- Syncope
When do the symptoms of aortic stenosis typically occur?
end-stage aortic stenosis - patients may remain asymptomatic for a long period until decompensation occurs with concurrent illness
Where is the ejection systolic murmur in aortic stenosis best heard?
second intercostal space on the right
What are 3 possible ECG findings of aortic stenosis?
- Increased QRS complex voltage
- Left axis deviation
- Poor R-wave progression
(findings related to left ventricular hypertrophy)
What are 2 possible CXR findings in aortic stenosis?
- Cardiomegaly
- Calcified aortic valve - if this is the cause
What is the primary test for the diagnosis and evaluation of severity in aortic stenosis?
Doppler echocardiography
What are 3 parameters that can judge AS as being severe?
- Peak pressure gradient >40 mmHg
- Valve area <1.0 cm2
- Aortic jet velocity >4 m/s
When can you get a falsely reassuring low peak pressure gradient in AS?
severe left ventricular dysfunction
What type of testing can be used to assess the true severity of asymptomatic patients with echocardiographically confirmed AS?
exercise testing
What type of imaging intervention can be used to provide additional detailed information on AS regarding valve morphology/dimensions of aortic root/extent of calcification?
cardiac MRI
What are 3 pieces of information that can be provided about AS from cardiac MRI?
- Valve morphology
- Dimensions of the aortic root
- Extent of valve calcification
Overall what are 5 investigations to perform in AS?
- ECG
- CXR
- Doppler echocardiography
- Exercise testing
- Cardiac MRI
What are 4 indications for intervention in aortic stenosis?
- all symptomatic patients
- asymptomatic with left ventricular ejetion fraction <50%
- asymptomatic patients with LVEF >50% who are physically active who have symptoms or drop in BP during exercise testing
- asymptomatic with LVEF >50% who have the following risk factors:
- aortic valve peak velocity >5.5 m/ss
- severe calcification and peak velocity progression >0.3 m/s2
- markedly elevated BNP levels without other explanation
- severe pulmonary hypertension (pulmonary artery systolic pressure >60 mmHg)
What are the 2 options for surgical procedures to perform valve replacement in aortic stenosis?
- Transcatheter aortic valve implantation (TAVI)
- Surgical aortic valve replacement (SAVR)
For which patients is TAVI the favoured method of valve replacement?
patients with severe comorbidities, previous heart surgery, frailty, resstricted mobility, those older than 75 years of age
For which patients is SAVR preferred for valvular replacement?
patients who are low risk and less than 75 yeras of age
What does the medical management of aortic stenosis involve?
standard treatment for heart failure - ACE inhibitors, beta blockers, diuretics
When is medical management for aortic stenosis preferred?
only when patients are unfit for either SAVR or TAVI, and have symptoms of concomitant heart failure
What monitoring should be performed for aortic stenosis?
- severe: every 6 months
- mild to moderate: yearly
- younger patients: every 2-3 years
What is aortic sclerosis?
asymptomatic condition that can be incidentally revealed through physical examination or via echocardiogram, caused by age-related senile degeneration of the valve
What are 2 ways that aortic sclerosis can be detected?
- Physical examination
- Echocardiogram
What causes aortic sclerosis?
age-related senile degeneration of the valve
What are 3 key features of aortic sclerosis on clinical examination?
- ejection systolic murmur that does not radiate to the carotids
- Normal S2
- Pulse character normal (not slow-rising)
- Normal pulse volume
What is the appearance of aortic sclerosis on echocardiography?
irregular aortic leaflet thickening and focal increased echogenicity
What distinguishes aortic sclerosis from aortic stenosis on echocardiography?
no impairment of leaflet excursion, and peak doppler velocities normal or only minimally elevated in aortic sclerosis rather than stenosis
