Aortic stenosis

Question 1

What are 4 clinical features of symptomatic disease?

Answer 1

1. Chest pain
2. Dyspnoea
3. Syncope
4. Murmur

Question 2

What is the murmur characteristic of aortic stenosis?

Answer 2

ejection systolic murmur (ESM)

Question 3

Where does the ejection systolic murmur typically radiate to?

Answer 3

carotids

Question 4

What can reduce the ejection systolic murmur of aortic stenosis?

Answer 4

Valsalva manoeuvre

Question 5

What are 6 signs of aortic stenosis on examination?

Answer 5

1. narrow pulse pressure
2. slow-rising pulse
3. delayed ejection systolic murmur
4. soft/absent S2
5. S4
6. thrill

Question 6

What is the most common cause of aortic stenosis in patients >65 years?

Answer 6

degenerative calcification

Question 7

What is the most common cause of aortic stenosis in patients <65 yeras?

Answer 7

bicuspid aortic valve (as opposed to tricuspid)

Question 8

What are 5 overall causes of aortic stenosis?

Answer 8

1. Degenerative calcification
2. Bicuspid aortic valve
3. William’s syndrome (supravalvular aortic stenosis)
4. Post-rheumatic disease
5. Subvalvular: hypertrophic obstructive cardiomyopathy (HOCM)

Question 9

What type of aortic stenosis is caused by William’s syndrome?

Answer 9

supravalvular

Question 10

What is an example of a cause of subvalvular aortic stenosis?

Answer 10

HOCM (hypertrophic obstructive cardiomyopathy)

Question 11

What is the management of asymptomatic aortic stenosis?

Answer 11

observe the patient

Question 12

What is the management of sympomatic aortic stenosis?

Answer 12

valve replacement

Question 13

What is the management of asymptomatic aortic stenosis when the valvular gradient is >40 mmHg and with features of left-ventricular systolic dysfunction?

Answer 13

consider surgery (despite being asymptomatic)

Question 14

What should be done prior to surgery for aortic stenosis and why?

Answer 14

angiogram - cardiovascular disease may coexist, may be able to combine procedures

Question 15

What is the management of patients with critical aortic stenosis who are not fit for valve replacement?

Answer 15

balloon valvuloplasty

Question 16

What is considered the triad of symptoms of aortic stenosis?

Answer 16

1. Dyspnoea
2. Angina
3. Syncope

Question 17

When do the symptoms of aortic stenosis typically occur?

Answer 17

end-stage aortic stenosis - patients may remain asymptomatic for a long period until decompensation occurs with concurrent illness

Question 18

Where is the ejection systolic murmur in aortic stenosis best heard?

Answer 18

second intercostal space on the right

Question 19

What are 3 possible ECG findings of aortic stenosis?

Answer 19

1. Increased QRS complex voltage
2. Left axis deviation
3. Poor R-wave progression

(findings related to left ventricular hypertrophy)

Question 20

What are 2 possible CXR findings in aortic stenosis?

Answer 20

1. Cardiomegaly
2. Calcified aortic valve - if this is the cause

Question 21

What is the primary test for the diagnosis and evaluation of severity in aortic stenosis?

Answer 21

Doppler echocardiography

Question 22

What are 3 parameters that can judge AS as being severe?

Answer 22

1. Peak pressure gradient >40 mmHg
2. Valve area <1.0 cm²
3. Aortic jet velocity >4 m/s

Question 23

When can you get a falsely reassuring low peak pressure gradient in AS?

Answer 23

severe left ventricular dysfunction

Question 24

What type of testing can be used to assess the true severity of asymptomatic patients with echocardiographically confirmed AS?

Answer 24

exercise testing

Question 25

What type of imaging intervention can be used to provide additional detailed information on AS regarding valve morphology/dimensions of aortic root/extent of calcification?

Answer 25

cardiac MRI

Question 26

What are 3 pieces of information that can be provided about AS from cardiac MRI?

Answer 26

1. Valve morphology 2. Dimensions of the aortic root 3. Extent of valve calcification

Question 27

Overall what are 5 investigations to perform in AS?

Answer 27

1. ECG 2. CXR 3. Doppler echocardiography 4. Exercise testing 5. Cardiac MRI

Question 28

What are 4 indications for intervention in aortic stenosis?

Answer 28

1. all symptomatic patients 2. asymptomatic with left ventricular ejetion fraction \<50% 3. asymptomatic patients with LVEF \>50% who are physically active who have symptoms or drop in BP during exercise testing 4. asymptomatic with LVEF \>50% who have the following risk factors: * aortic valve peak velocity \>5.5 m/s^s * severe calcification and peak velocity progression \>0.3 m/s² * markedly elevated BNP levels without other explanation * severe pulmonary hypertension (pulmonary artery systolic pressure \>60 mmHg)

Question 29

What are the 2 options for surgical procedures to perform valve replacement in aortic stenosis?

Answer 29

1. Transcatheter aortic valve implantation (TAVI) 2. Surgical aortic valve replacement (SAVR)

Question 30

For which patients is TAVI the favoured method of valve replacement?

Answer 30

patients with severe comorbidities, previous heart surgery, frailty, resstricted mobility, those older than 75 years of age

Question 31

For which patients is SAVR preferred for valvular replacement?

Answer 31

patients who are low risk and less than 75 yeras of age

Question 32

What does the medical management of aortic stenosis involve?

Answer 32

standard treatment for heart failure - ACE inhibitors, beta blockers, diuretics

Question 33

When is medical management for aortic stenosis preferred?

Answer 33

only when patients are unfit for either SAVR or TAVI, and have symptoms of concomitant heart failure

Question 34

What monitoring should be performed for aortic stenosis?

Answer 34

* severe: every 6 months * mild to moderate: yearly * younger patients: every 2-3 years

Question 35

What is aortic sclerosis?

Answer 35

asymptomatic condition that can be incidentally revealed through physical examination or via echocardiogram, caused by age-related senile degeneration of the valve

Question 36

What are 2 ways that aortic sclerosis can be detected?

Answer 36

1. Physical examination 2. Echocardiogram

Question 37

What causes aortic sclerosis?

Answer 37

age-related senile degeneration of the valve

Question 38

What are 3 key features of aortic sclerosis on clinical examination?

Answer 38

1. ejection systolic murmur that does not radiate to the carotids 2. Normal S2 3. Pulse character normal (not slow-rising) 4. Normal pulse volume

Question 39

What is the appearance of aortic sclerosis on echocardiography?

Answer 39

irregular aortic leaflet thickening and focal increased echogenicity

Question 40

What distinguishes aortic sclerosis from aortic stenosis on echocardiography?

Answer 40

no impairment of leaflet excursion, and peak doppler velocities normal or only minimally elevated in aortic sclerosis rather than stenosis