Aortic Stenosis Flashcards
(11 cards)
Clinical signs of Aortic Stenosis
- Slow rising, low volume pulse
- Narrow pulse pressure
- Apex beat is sustained in stenosis (HP: heaving pressure‐loaded)
- Thrill in aortic area (right sternal edge, second intercostal space)
- Auscultation:
- A crescendo-decrescendo, ejection systolic murmur (ESM) loudest in the aortic area during expiration and radiating to the carotids.
- Severity: soft and delayed A2 due to immobile leaflets and prolonged LV emptying, delayed (not loud) ESM, fourth heart sound S4.
Auscultation in Aortic stenosis
A crescendo-decrescendo, ejection systolic murmur (ESM) loudest in the aortic area during expiration and radiating to the carotids.
Severity:
- Soft and delayed A2 due to immobile leaflets and prolonged LV emptying,
- delayed (not loud) ESM,
- fourth heart sound S4
Evidence of complications in Aortic stenosis
- Endocarditis: Splinters, Osler’s nodes (finger pulp), Janeway lesions (palms), Roth spots (retina), temperature, splenomegaly and haematuria
- Left ventricular dysfunction: Dyspnoea, displaced apex and bibasal crackles
- Conduction problems:
- -> acute, endocarditis;
- -> chronic, calcified aortic valve node
Differential diagnosis of Aortic stenosis
- HOCM
- VSD
- Aortic sclerosis: normal pulse character and no radiation of murmur
- Aortic flow: high output clinical states e.g. pregnancy or anaemia
Causes of Aortic stenosis
- Congenital: bicuspid aortic valve
- Acquired:
- -> Age (senile degeneration and calcification);
- -> Streptococcal (rheumatic)
Associations of Aortic stenosis
ABC
- Angiodysplasia
- Bicuspid aortic valve
- Coarctation
Severity of Aortic stenosis
- Signs Auscultation features: Soft and delayed A2 due to immobile leaflets and prolonged LV emptying, delayed (not loud) ESM, fourth heart sound S4
- Mortality risk:
- Angina 50% mortality at 5 years
- Syncope 50% mortality at 3 years
- Breathlessness 50% mortality at 2 years - Biventricular failure (right ventricular failure is preterminal)
Investigations in Aortic stenosis
- ECG: LVH on voltage criteria, conduction defect (prolonged PR interval)
- CXR: often normal; calcified valve
- Echo: mean gradient: >40 mm Hg aortic (valve area <1.0 cm2) if severe
- Catheter: invasive transvalvular gradient and coronary angiography (coronary artery disease often coexists with aortic stenosis)
Management of Aortic Stenosis
*• Asymptomatic
⚬⚬ None specific, good dental health
⚬⚬ Regular review: symptoms and echo to assess gradient and LV function
*• Symptomatic
A- ⚬⚬ Surgical
1- ⚬⚬ Aortic valve replacement +/− CABG
2- ⚬⚬ Operative mortality 3–5% depending on the patient’s EuroScore (www.euroscore.org/calc.html)
B- ⚬⚬ Percutaneous
1- ⚬⚬ Balloon aortic valvuloplasty (BAV)
2- ⚬⚬ Transcutaneous aortic valve implantation (TAVI)
a- ⚬⚬ Transfemoral (or transapical and transaortic)
b- ⚬⚬ Maybe recommended
–> if high surgical risk (logEuroscore >20%) or
–> inoperable cases (number needed to treat to prevent death at 1 year = 5)
Duke’s criteria for infective endocarditis
Major:
- Typical organism in two blood cultures
- Echo: abscess, large vegetation, dehiscence*
Minor:
- Pyrexia >38°C
- Echo suggestive
- Predisposed, e.g. prosthetic valve
- Vascular phenomenon, including major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, or Janeway lesions
- Immunologic/Vasculitic phenomenon such as glomerulonephritis, Osler nodes, Roth spots, and rheumatoid factor, (ESR↑, CRP↑)
- Atypical organism on blood culture
==> Diagnose if the patient has 2 major, 1 major and 2 minor, or 5 minor criteria. (* plus heart failure/refractory to antibiotics/heart block are indicators for urgent surgery).
Indications for antibiotic prophylaxis for Infective Endocarditis
Antibiotic prophylaxis is now limited to those with
1- Prosthetic valves,
2- Previous endocarditis,
3- Cardiac transplants with valvulopathy and
4- Certain types of congenital heart disease.
