Aortic stenosis (Complete) Flashcards
Define aortic stenosis
Type of aortic valve disease characterised by pathological narrowing of the aortic valve leading to blood flow obstruction.
Give 6 examples of pathological causes of aortic stenosis.
Degenerative calcification
Fibrosis
Bicuspid aortic valve
Post-rheumatic disease
William’s syndrome (supra-valvular aortic stenosis)
Subvalvular aortic stenosis (e.g. hypertrophic obstructive cardiomyopathy)
What cause of aortic stenosis is most common in > 65 year olds?
Degenerative calcinosis
What cause of aortic stenosis is most common in under 65 year olds?
Bicuspid aortic valve
What are the main signs/symptoms of aortic stenosis? (11)
Classic triad of symptoms:
Chest pain (angina/exertional chest pain)
Exertional dyspnoea
Syncope/pre-syncope (exertional)
N.B. Symptoms of heart failure
Signs:
Ejection systolic murmur (tend to radiate to the carotids)
Slow rising carotid pulse (severe stenosis)
Narrow pulse pressure (severe stenosis)
Soft/absent S2 (severe stenosis)
S4 (severe stenosis)
Thrill (severe stenosis)
Left ventricular hypertrophy or failure (severe stenosis)
What type of murmur is indicative of aortic stenosis? What are the main characteristics of this murmur?
Ejection systolic murmur
Tends to radiate to the carotid artery
Murmur is decreased following valsalva maneouvre
What is the valsalva mannoeuvre?
Breathing method that may slow your heart when it’s beating too fast. To do it, you breathe out strongly through your mouth while holding your nose tightly closed.
What signs are indicative of severe aortic stenosis? (7)
Narrow pulse pressure
Slow rising pulse
Delayed ejection systolic murmur
Soft/absent S2
S4
Thrill
Left ventricular hypertrophy or failure (e.g. displaced apex beat)
What are some risk factors for aortic stenosis? (4)
Age > 60 years
Congenital bicuspid valve
Rheumatic heart disease
Chronic kidney disease (speeds up calcification)
What are the main investigations performed in patients suspected of having aortic stenosis? (3)
Bedside:
ECG: may show left ventricular hypertrophy
Imaging/Invasive:
Echocardiogram: may show elevated aortic pressure gradient.
CXR: May be normal or show cardiomegaly, aortic valve calcification and/or pulmonary congestion
What additional investigations which can be considered in patients suspected of having aortic stenosis to assess severity? (2)
Exercise testing (useful for physically active patients)
Cardiac CT
What investigation is diagnostic for aortic stenosis?
Echocardiogram
When should a 2 week urgent referal to a specialist (alongside echocardiography) be considered in patients suspected of aortic stenosis?
Adults with a systolic murmur and exertional syncope.
Murmur and severe symptoms (angina or breathlessness on minimal exertion or at rest)
What is the management plan for patients diagnosed with aortic stenosis?
If mild valvular disease (e.g. assymptomatic and findings on echocardiogram): Observation only
If symptomatic: Valvular replacement
Other invasive options:
Balloon valvuloplasty: In children with no calcification OR if valve replacement is contraindicted
Pharmacological management:Only for treatment of co-morbities such as HF:
Beta-blockers
ACE
Diuretics
What are the two main options for aortic valve replacement? When would you choose one option over the other?
Surgical aortic valve replacement: Patients who are low risk and < 75 years of age.
Transcatheteric aortic valve implantation [TAVI]: used for patients with a high operative risk (e.g. elderly)
What additional investigation tends to be performed prior to surgical aortic valvular replacement (SAVR) and why?
Angiogram
Done to identify other cardiovascular diseases so that surgical procedures can be combined into one.
