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AIP Chest pain > Aortic stenosis > Flashcards

Aortic stenosis Flashcards

1
Q

What are 4 clinical features of symptomatic disease?

A
  1. Chest pain
  2. Dyspnoea
  3. Syncope
  4. Murmur
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2
Q

What is the murmur characteristic of aortic stenosis?

A

ejection systolic murmur (ESM)

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3
Q

Where does the ejection systolic murmur typically radiate to?

A

carotids

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4
Q

What can reduce the ejection systolic murmur of aortic stenosis?

A

Valsalva manoeuvre

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5
Q

What are 6 signs of aortic stenosis on examination?

A
  1. narrow pulse pressure
  2. slow-rising pulse
  3. delayed ejection systolic murmur
  4. soft/absent S2
  5. S4
  6. thrill
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6
Q

What is the most common cause of aortic stenosis in patients >65 years?

A

degenerative calcification

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7
Q

What is the most common cause of aortic stenosis in patients <65 yeras?

A

bicuspid aortic valve (as opposed to tricuspid)

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8
Q

What are 5 overall causes of aortic stenosis?

A
  1. Degenerative calcification
  2. Bicuspid aortic valve
  3. William’s syndrome (supravalvular aortic stenosis)
  4. Post-rheumatic disease
  5. Subvalvular: hypertrophic obstructive cardiomyopathy (HOCM)
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9
Q

What type of aortic stenosis is caused by William’s syndrome?

A

supravalvular

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10
Q

What is an example of a cause of subvalvular aortic stenosis?

A

HOCM (hypertrophic obstructive cardiomyopathy)

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11
Q

What is the management of asymptomatic aortic stenosis?

A

observe the patient

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12
Q

What is the management of sympomatic aortic stenosis?

A

valve replacement

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13
Q

What is the management of asymptomatic aortic stenosis when the valvular gradient is >40 mmHg and with features of left-ventricular systolic dysfunction?

A

consider surgery (despite being asymptomatic)

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14
Q

What should be done prior to surgery for aortic stenosis and why?

A

angiogram - cardiovascular disease may coexist, may be able to combine procedures

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15
Q

What is the management of patients with critical aortic stenosis who are not fit for valve replacement?

A

balloon valvuloplasty

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16
Q

What is considered the triad of symptoms of aortic stenosis?

A
  1. Dyspnoea
  2. Angina
  3. Syncope
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17
Q

When do the symptoms of aortic stenosis typically occur?

A

end-stage aortic stenosis - patients may remain asymptomatic for a long period until decompensation occurs with concurrent illness

18
Q

Where is the ejection systolic murmur in aortic stenosis best heard?

A

second intercostal space on the right

19
Q

What are 3 possible ECG findings of aortic stenosis?

A
  1. Increased QRS complex voltage
  2. Left axis deviation
  3. Poor R-wave progression

(findings related to left ventricular hypertrophy)

20
Q

What are 2 possible CXR findings in aortic stenosis?

A
  1. Cardiomegaly
  2. Calcified aortic valve - if this is the cause
21
Q

What is the primary test for the diagnosis and evaluation of severity in aortic stenosis?

A

Doppler echocardiography

22
Q

What are 3 parameters that can judge AS as being severe?

A
  1. Peak pressure gradient >40 mmHg
  2. Valve area <1.0 cm2
  3. Aortic jet velocity >4 m/s
23
Q

When can you get a falsely reassuring low peak pressure gradient in AS?

A

severe left ventricular dysfunction

24
Q

What type of testing can be used to assess the true severity of asymptomatic patients with echocardiographically confirmed AS?

A

exercise testing

25
Q

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?

A

cardiac MRI

26
Q

What are 3 pieces of information that can be provided about AS from cardiac MRI?

A
  1. Valve morphology
  2. Dimensions of the aortic root
  3. Extent of valve calcification
27
Q

Overall what are 5 investigations to perform in AS?

A
  1. ECG
  2. CXR
  3. Doppler echocardiography
  4. Exercise testing
  5. Cardiac MRI
28
Q

What are 4 indications for intervention in aortic stenosis?

A
  1. all symptomatic patients
  2. asymptomatic with left ventricular ejetion fraction <50%
  3. asymptomatic patients with LVEF >50% who are physically active who have symptoms or drop in BP during exercise testing
  4. 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)
29
Q

What are the 2 options for surgical procedures to perform valve replacement in aortic stenosis?

A
  1. Transcatheter aortic valve implantation (TAVI)
  2. Surgical aortic valve replacement (SAVR)
30
Q

For which patients is TAVI the favoured method of valve replacement?

A

patients with severe comorbidities, previous heart surgery, frailty, resstricted mobility, those older than 75 years of age

31
Q

For which patients is SAVR preferred for valvular replacement?

A

patients who are low risk and less than 75 yeras of age

32
Q

What does the medical management of aortic stenosis involve?

A

standard treatment for heart failure - ACE inhibitors, beta blockers, diuretics

33
Q

When is medical management for aortic stenosis preferred?

A

only when patients are unfit for either SAVR or TAVI, and have symptoms of concomitant heart failure

34
Q

What monitoring should be performed for aortic stenosis?

A
  • severe: every 6 months
  • mild to moderate: yearly
  • younger patients: every 2-3 years
35
Q

What is aortic sclerosis?

A

asymptomatic condition that can be incidentally revealed through physical examination or via echocardiogram, caused by age-related senile degeneration of the valve

36
Q

What are 2 ways that aortic sclerosis can be detected?

A
  1. Physical examination
  2. Echocardiogram
37
Q

What causes aortic sclerosis?

A

age-related senile degeneration of the valve

38
Q

What are 3 key features of aortic sclerosis on clinical examination?

A
  1. ejection systolic murmur that does not radiate to the carotids
  2. Normal S2
  3. Pulse character normal (not slow-rising)
  4. Normal pulse volume
39
Q

What is the appearance of aortic sclerosis on echocardiography?

A

irregular aortic leaflet thickening and focal increased echogenicity

40
Q

What distinguishes aortic sclerosis from aortic stenosis on echocardiography?

A

no impairment of leaflet excursion, and peak doppler velocities normal or only minimally elevated in aortic sclerosis rather than stenosis

AIP Chest pain (9 decks)

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