Review Question - QID 107867

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Aortic Stenosis Treatment Operative QID: 107867 (M2.CV.16.4694)

QID 107867 (Type "107867" in App Search)

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?

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Cessation of exercise and pharmacotherapy with beta blockers.

17%

1/6

High dose statin and 81mg aspirin

0/6

Surgical evaluation for aortic valve replacement

50%

3/6

Treatment with ACE-inhibitors and beta blockers

0/6

Observation with echocardiographic monitoring

17%

1/6

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This patient has signs and symptoms of severe aortic stenosis (AS) (Illustration A). Aortic stenosis requires prompt surgical evaluation and correction in order to prevent further complications and cardiac strain.

AS is a disease of the elderly, with nearly 13% prevalence in patients 75 years of age and older. AS can be congenital or due to chronic hypertension resulting in calcification and valve orifice narrowing. Over time, the increased pressure needed to maintain systolic pressure can result in left ventricular hypertrophy and even left sided heart failure. Treatment is predominantly surgical, with open valve repair being the treatment of choice. Balloon valvuloplasty can be considered in patients with severe AS as a bridge to surgery. Transcatheter aortic valve replacement (TAVR) is the treatment of choice for patients deemed too sick for open cardiac surgery.

Figure A shows an EKG with evidence of left ventricular (LV) hypertrophy with increased LV voltages: S wave in V1 + R wave in V6 > 35 mm; R wave in aVL > 11 mm. In addition, the EKG exhibits LV strain pattern: T wave inversion in the lateral leads I, aVL, and V5-V6, as well as left axis deviation. Figure B shows an aortic valve view on echocardiogram demonstrating mean peak pressure gradients of >80 mm Hg (labeled as "AVmeanPG" in the top left), diagnostic for severe aortic stenosis. Illustration A shows a chart detailing degrees of aortic stenosis as a function of the mean gradients across the aortic valve and aortic valve orifice area.

Incorrect Answers:
Answer 1: This is appropriate management for hypertrophic cardiomyopathy, not AS.
Answer 2: High dose statin and baby aspirin are pharmacotherapies for atherosclerosis. Although atherosclerosis is involved in the pathogenesis of AS, statins and aspirin play no role in the management of symptomatic AS.
Answer 4: ACE-inhibitors and beta blockers have shown mortality benefits in patients with congestive heart failure, but medical therapy has a limited role in the treatment of AS.
Answer 5: Observation with serial echocardiographic studies is an appropriate management strategy for patients with asymptomatic AS. This patient is not only symptomatic, but also shows severe grade AS on echocardiography.

ILLUSTRATIONS:

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