FN: Aortic Stenosis Flashcards Preview

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Flashcards in FN: Aortic Stenosis Deck (25):
1

Causes

Senile calcification (60yrs+): commonest
Congenital: Bicuspic valve 40-60rs), Williams syn.
Rheumatic fever

2

Symptoms TRIAD

Angina
Dyspnoea
Syncope (esp. with excercise)

3

Symptoms other

PND, orthopnoea, frothy sputum
Arrhythmias
Systemic emboli if endocarditis
Suddern death

4

Signs

1. Slow rising pulse with narrow PP
2. Aortic Thrill
3. Apex: forceful, non-displaced (pressure overload)
4. Heart sounds
Quiet A2
Early syst. ejection click if pliable (young) valve
S4 (foceful A contraction vs. hypertrophied V)
5. Murmur
ESM
Right 2nd ICS
Sitting forward in end-expiration
Radiates to carotids

5

Clinical indicators of Severe AS

Quiet/absent A2
S4
Narrow pulse pressure
Decompensation: LVF

6

Differentials

Coronary artery disease
MR
Aortic sclerosis
HOCM

7

Aortic sclerosis

1. Valve thickening: no pressure gradient
2. turbulence --> murmur
3. ESM with no radiation and normal pulse

8

HOCM

ESM murmur whcih increases in intensity with valsalva (AS redcued)

9

Aortic Stenosis

Valve narrow due to fusion of the commissures
Narrow PP, slow rising pulse
Forceful apex
ESM radiating --> carotid
ECG: LVF

10

Aortic Sclerosis

Valve thickening
ESM with no radiation

11

Investigations

Bloods
ECG
CXR
Echo + Doppler
Cardiac Catheterisation + Angiography
Excercise stress Test

12

Bloods

FBC
U+E
Lipids
Glucose

13

ECG

LVH
LV strain: tall R, ST depression, T inversion inV4-V6
LBBB or complete AV block (septal calcification) (may need pacing)

14

CXR

Calcified AV (esp. on lateral films)
LVH
Evidence of failure
Post-stenotic aortic dilatation

15

Echo + Doppler

Diagnostic
Thickened, calcified, immobile valve cusps
Severe AS (AHA/ACC 2006 guidelines)

16

Severe AS (AHA/ACC 2006 guidelines)

Pressure gradient >40mmHg
Jet velocity >4 m/s (or increase by 0.3 m/s ina yr)
Valve area <1 cm2

17

Cardiac Catheterisation + Angiography

Can assess valve gradient and LV function
Assess coronaries in all pts. planned for surgery

18

Excerise Stres test

contraindicated if symptomatic AS
May be useful to assess ex capacity in asympto pts.

19

Management

Medical and Surgical

20

Medical

Optimies RFs: statins, anti-hypertensives, DM
Monitor: regular f/up with echo
Angina: beta - blockers
Heart failure: ACEi and diuretics
Avoid nitrates

21

Prognosis if symptomatic

Poor prognosis if symptomatic
1. Angina/syncope: 2-3 yrs
LVF: 1-2 yrs

22

Indications for valve replacement

Severe symptomatic AS
Severe asymptomatic AS with reduced EF (<50%)
Severe AS undergoing CABG or other valve op

23

Valve types

Mechanical valves lasts longer but need for anticoagulation: young patients

Bioprosthetic dont require anticoagulation but fail sooner

24

Options for unfit patients

Balloon Valvuloplasty - limited use in adults as complications rate is high (>10%) and re-stenosis occurs in 6-12 months

Transcatheter Aortic Valve Implantation (TAVI)

25

TAVI

Folded valve deployed in aortic root
Increased perioperative stroke risk cf. replacement
Decrease major bleeding
Similar survival @ 1 yr
Little long-term data

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