Aortic Stenosis

Question 1

Mr JJ, a 67 y.o. male returns from holiday to see his GP. While he was away, he developed exertional chest pain which a local Dr dx-ed as angina of effort. he gives a classical hx of ischaemic cardiac chest pain on exercise and, on examination, you find him to have a BP 110/85 and a slow rising pulse. you suspect he might have aortic stenosis and refer him to the cardiologists directly.

Answer 1

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Question 2

a) apart from exertional chest pain, name 2 other sx from which a pt with AS might suffer.

Answer 2

• dyspnoea
• exertional syncope
• sudden cardiac death

Question 3

b) please list 3 features of the murmur you would expect to elicit and give 3 other features associated with AS.

Answer 3

• cresendo-decresendo pattern
• radiates to carotids
• loudest at 2nd right interspace
• soft or absent S2
• slow rising, low volume pulse (or weak/late)
• narrow pulse pressure
• displaced apex beat
• LV heave

Question 4

c) please describe, in less than 50 words, why pts with AS may experience chest pain.

Answer 4

• LV undergoes concentric hypertrophy in response to the high systolic pressure (pressure gradient) requiring more O2 but does not receive it (supply-demand mismatch) causing ischaemia
• stenosed aortic valve => not enough blood reaching coronary vessels

*may also experience pain due to concomitant CAD

Question 5

d) what is the most important ix to identify the cause of Mr JJ’s problem?

Answer 5

ECHO: assess pressure gradient and surface area of valve

Question 6

e) list 2 abnormalities you might identify (during this above ix).

Answer 6

1) thickened calcified aortic valve cusps
2) elevated aortic pressure gradient (>40mmHg across the valve)
3) reduced valve area (1cm2)
4) reduced LVEF
5) LVH

Question 7

f) the cardiologist recommends cardiac catheterisation. why is this invasive test indicated?

Answer 7

to determine whether he has coexisting CAD. if so, it can be treated at the same time as the valve procedure.