Updated: 12/3/2020

Aortic Stenosis

0%
Topic
Review Topic
0
0
N/A
N/A
Questions
12
0
0
0%
0%
Evidence
8
0
0
0%
0%
Videos / Pods
1
Topic
Snapshot
  • A 74-year-old man reports a 3-month history of intermittent chest pain, syncopal episodes, and dyspnea on exertion. He has a long-standing history of coronary artery disease and hypertension. Physical exam reveals a systolic crescendo-decrescendo murmur, heard best at the heart base and radiates to the carotids. He is sent for further evaluation with an echocardiogram.
Introduction
  • Clinical definition
    • narrowing of the aortic valve
  • Epidemiology
    • demographics
      • bicuspid aortic valve calcification 
        • presents at a younger age 
      • tricuspid aortic valve calcification
        • > 65 years of age
    • risk factors
      • hypertension
      • coronary artery disease
      • rheumatic heart disease
  • Etiology
    • age-related dystrophic calcification of normal (tricuspid) aortic valve in older patients  
    • calcification of bicuspid aortic valve in younger patients 
  • Pathogenesis
    • atherosclerosis can lead to plaque formation and calcium deposits on the aortic valve
    • aortic stenosis results in ↑ left heart pressure → left ventricular hypertrophy (LVH) 
    • LVH and stiff, noncompliant walls result in ↑ oxygen demand and clinically manifests as angina
    • over time, aortic stenosis results in ↓ blood flow to the vertebral, basilar, and carotid arteries, resulting clinically in syncope
  • Associated conditions
    • hemolytic anemia
  • Prognosis
    • often asymptomatic
    • once symptomatic, most patients require aortic valve replacement
Presentation
  • Symptoms
    • heart failure
    • SAD
      • Syncope 
      • Angina or chest pain (most common)
      • Dyspnea
  • Physical exam
    • systolic ejection murmur
      • heard best at heart base
      • may have ejection click
      • radiates to carotid arteries
      • crescendo-decrescendo murmur
      • decreases with standing, Valsalva, or handgrip
      • increases with amyl nitrate, squat, or leg raise
      • single, soft S2 
        • suggestive of severe aortic stenosis
    • S4 heart sound
      • from stiff or hypertrophic ventricle
    • paradoxical splitting of S2
      • heard on expiration rather than inspiration
    • pulsus parvus et tardus 
      • weak pulses with a delayed peak
Imaging
  • Radiography 
    • indication
      • for all patients
    • findings
      • cardiomegaly
      • calcification
      • pulmonary congestion
  • Echocardiography    
    • indications
      • for all patients
      • diagnostic test
    • views
      • transthoracic echocardiogram (TTE) initially
      • transesophageal echocardiogram (TEE) is more accurate
    • findings
      • thick aortic valve leaflets
      • aortic valve anatomic abnormalities
      • LVH
Studies
  • Electrocardiogram (ECG)
    • indications
      • for all patients
    • findings
      • LVH
  • Left heart catheterization
    • indications
      • most accurate diagnostic test
      • to assess pressure gradient across the valve
      • only indicated to confirm the diagnosis if echocardiography is unclear
    • findings
      • elevated pressure gradient (> 30 mmHg)
  • Making the diagnosis
    • based on clinical presentation and echocardiogram
Differential
  • Hypertrophic cardiomyopathy
    • distinguishing factor
      • normal aortic valve on echo and murmur that does not radiate to the carotids
Treatment
  • Medical
    • diuretics
      • indication
        • best initial therapy for all patients with pulmonary congestion
  • Operative
    • aortic valve replacement
      • indication
        • definitive treatment
        • if patients are symptomatic
        • if aortic valve area is < 0.8 cm2 (normal 2.5-3 cm2)
        • if ejection fraction < 50%
      • modalities
        • bioprosthetic valves require more frequent replacement but do not require anticoagulation
        • mechanical valves are not replaced as often but must be treated with anticoagulation
    • balloon valvuloplasty
      • indication
        • in patients too ill for surgery
Complications
  • Arrhythmia
  • Heart failure
  • Endocarditis

Please rate topic.

Average 4.8 of 6 Ratings

Questions (12)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(M2.CV.16.4694) A 74-year-old female with a history of hypertension, dyslipidemia, and osteoarthritis presents to her primary care physician because of worsening shortness of breath and intermittent chest discomfort. The patient reports that she is usually able to walk five blocks around her cul de sac, but lately this same walk causes her these symptoms. She also complains of mild chest pain that began yesterday. Vital signs are as follows: T 98.8 F, HR 90 bpm, BP 150/100 mmHG, RR 15, O2 Sat 96%. On exam, carotid pulses are noted to be delayed from the cardiac cycle. Cardiac auscultation is notable for a late-peaking crescendo-decrescendo systolic ejection murmur loudest over the right upper sternal border. The patient is referred to the emergency department, where cardiac enzymes are negative. An EKG is shown in Figure A. The patient is referred for an echocardiogram, and pressure gradient recordings across the aortic valve are shown in Figure B. Which of the following is the appropriate next step for this patient?

QID: 107867
FIGURES:
1

Cessation of exercise and pharmacotherapy with beta blockers.

25%

(1/4)

2

High dose statin and 81mg aspirin

0%

(0/4)

3

Surgical evaluation for aortic valve replacement

50%

(2/4)

4

Treatment with ACE-inhibitors and beta blockers

0%

(0/4)

5

Observation with echocardiographic monitoring

0%

(0/4)

M 7 E

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(M2.CV.14.132) A 36-year-old man presents to the emergency room with subacute worsening of chronic chest pain and shortness of breath with exertion. The patient is generally healthy, lifts weights regularly, and does not smoke. His temperature is 97.8°F (36.6°C), blood pressure is 122/83 mm Hg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air. Cardiac auscultation reveals a crescendo-decrescendo murmur heard right of the upper sternal border with radiation into the carotids. An ECG shows left axis deviation and meets criteria for left ventricular hypertrophy. An initial troponin is < 0.01 ng/mL. Which of the following is the most likely diagnosis?

QID: 100648
1

Bacterial endocarditis

1%

(1/101)

2

Bicuspid aortic valve

93%

(94/101)

3

Cardiac myxoma

2%

(2/101)

4

Mitral insufficiency

1%

(1/101)

5

Senile calcific changes

2%

(2/101)

M 6 E

Select Answer to see Preferred Response

(M2.CV.13.210) A 72-year-old female presents to the emergency department following a syncopal episode while walking down several flights of stairs. The patient has not seen a doctor in several years and does not take any medications. Your work-up demonstrates that she has symptoms of angina and congestive heart failure. Temperature is 36.8 degrees Celsius, blood pressure is 160/80 mmHg, heart rate is 81/min, and respiratory rate is 20/min. Physical examination is notable for a 3/6 crescendo-decrescendo systolic murmur present at the right upper sternal border with radiation to the carotid arteries. Random blood glucose is 205 mg/dL. Which of the following portends the worst prognosis in this patient?

QID: 106193
1

Syncope

18%

(5/28)

2

Angina

14%

(4/28)

3

Congestive heart failure (CHF)

46%

(13/28)

4

Hypertension

4%

(1/28)

5

Diabetes

14%

(4/28)

M 7 B

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Evidence (8)
VIDEOS & PODCASTS (1)
EXPERT COMMENTS (26)
Private Note