Updated: 5/22/2019

Aortic Stenosis

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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
    • 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
 

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Questions (8)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.CV.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? Review Topic

QID: 100648
1

Bacterial endocarditis

1%

(1/97)

2

Bicuspid aortic valve

94%

(91/97)

3

Cardiac myxoma

1%

(1/97)

4

Mitral insufficiency

1%

(1/97)

5

Senile calcific changes

2%

(2/97)

M2

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(M2.CV.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? Review Topic

QID: 107867
FIGURES:
1

Cessation of exercise and pharmacotherapy with beta blockers.

0%

(0/0)

2

High dose statin and 81mg aspirin

0%

(0/0)

3

Surgical evaluation for aortic valve replacement

0%

(0/0)

4

Treatment with ACE-inhibitors and beta blockers

0%

(0/0)

5

Observation with echocardiographic monitoring

0%

(0/0)

M2

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(M2.CV.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? Review Topic

QID: 106193
1

Syncope

14%

(3/21)

2

Angina

10%

(2/21)

3

Congestive heart failure (CHF)

52%

(11/21)

4

Hypertension

5%

(1/21)

5

Diabetes

14%

(3/21)

M2

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