Aortic Stenosis – Quickly review with flashcards

Aortic stenosis is a common case found during OSCEs as well as in practice.
In the following flashcards, try answering the question in your head first and then read the answer (by hovering the mouse pointer over the card or by touching mobiles/tablets). This way you will be able to retain the topic’s important points.

What are the causes that can lead to aortic stenosis?

Senile calcification -commonest

Congenital abnormalities – Bicuspid aortic valve & Williams syndrome

Rheumatic heart disease –  in developing countries

How does aortic stenosis can present?

Aortic stenosis can present with chest pain, dyspnoea on exertion, dizziness or faints, systemic emboli if there is infective endocarditis, and rarely as sudden death.

The classic triad includes angina, syncope, and heart failure. Think of Aortic stenosis in any elderly person with chest pain, syncope or exertional shortness of breath.

What are the signs that can be elicited in aortic stenosis?

Pulse is usually slow rising. Carotid pulse will be low in volume and its upstroke will be delayed. This is known as pulsus parvus et tardus.

Pulse pressure will be narrow.

Apex beat will be heaving and un-displaced.

Thrill may be palpable in aortic area.

On auscultation, S1 is usually normal. As stenosis worsens, A2 is increasingly delayed, giving first a single S2 and then reversed splitting. In severe aortic stenosis, A2 may become inaudible due to calcified valve. Rarely, there may be an ejection click indicating a pliable valve. There may be S4 due to left ventricular hypertrophy.

Murmur in aortic stenosis is ejection systolic murmur. It is heard at the base, left sternal edge and the aortic area. Murmur radiates to the carotids.

What investigations you will do and how would they help you?

ECG:  may reveal LVH with strain pattern, P-mitrale, Left axis deviation. Left bundle branch block or complete AV block may be found with calcified aortic ring.

Chest radiograph: may show Left ventricular hypertrophy and calcified aortic valve. Poststenotic dilatation of ascending aorta may also be noticed in cases of aortic stenosis secondary to bicuspid aortic valve.

Echocardiography with doppler: It is the diagnostic modality of choice. Doppler echo can estimate the gradient across valves. The stenosis is severe if valve area is < 1cm2 and peak gradient is greater than 40 mmHg. Gradient across the valve may be underestimated in cases of poor left ventricle function, because it will be unable to generate gradient.

If the aortic jet velocity is > 4 m/s, or if it is increasing by > 0.3 m/s per year, risk of complications is increased.

Cardiac catheterization is not routinely done in all cases. It can assess valve gradient, LV function, and coronary artery disease.

How will you manage aortic stenosis?

Medical treatment may stabilize heart failure.

Control of systemic hypertension is important to reduce excess afterload.

Surgical treatment

Surgical valve replacement is the definitive treatment for aortic stenosis.

Prompt valve replacement shall be done in symptomatic individuals. If the patient is asymptomatic, surgical valve replacement is still considered if aortic stenosis is severe and there is a deteriorating ECG.

If the patient is not medically fit for surgery, percutaneous valvuloplasty or transcatheter aortic valve implantation shall be done.

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