Week Four - Case Three

Question 1

what is aortic stenosis

Answer 1

the narrowing of the three cusps that form the aortic valve

Question 2

what are the congenital causes of aortic stenosis

Answer 2

Bicuspid Valve
Williams Syndrome

Question 3

what is the most common cause of aortic stenosis

Answer 3

senile calcification
Look for corneal arcus

Question 4

what are the signs of aortic stenosis

Answer 4

Ejection Systolic murmur best heard in the aortic area, ( Right 2nd intercostal space at border of sternum), radiating to the caroitds.

Slow-rising pulse, with a narrow pulse pressure (difference between systolic and diastolic pressures is small)

Heave – but apex beat is not displaced

Possible signs of:
- Heart failure / pulmonary hypertension: crackles at the lung bases, pink frothy sputum, oedema etc
- AF – irregularly irregular pulse

Question 5

what are the symptoms of aortic stenosis

Answer 5

Angina
Syncope
Dyspnoea

Signs of any valve defect
Fatigue
Dyspnoea

Question 6

what would an ECG show

Answer 6

L – LBBB – due do calcification
L – Left Axis Deviation
L – LVH
P – Poor R wave progression (i.e. depolarisation of the ventricles is slow)

Question 7

what is used to estimate the pressure across the valve

Answer 7

a doppler echo

Question 8

what are the pressure readings indicative of aortic stenosis

Answer 8

0 mmHg – normal valve

<30 mmHg – mild aortic stenosis

30-50 mmHg – moderate aortic stenosis

> 50 mmHg – severe aortic stenosis

Question 9

what is cardiac catheritisation

Answer 9

this can assess the actual gradient across the valve as well as check for co-existing CADw

Question 10

what is the prognosis of aortic stenosis if it goes untreated

Answer 10

This can be predicted with the presence of symptoms:
Angina present – 2 years
Syncope present – 1 year
Dyspnoea present – 6 months

Question 11

what is the surgical management of aortic stenosis

Answer 11

Surgical –if symptomatic, then the prognosis is poor (above) and prompt valve replacement is recommended. Valve replacement is also recommended for patients with ECG signs, and moderate to severe disease on Doppler / cardiac catheterisation.

Patients should be placed on antibiotics to prevent bacterial endocarditis

Question 12

how long to prosthetic valve replacements last

Answer 12

about 10 years, they may need a replacement

no need for long term anticoagulant therapy

Question 13

what are the three types of a metal valve, how long do they last and what is the disadvantage

Answer 13

Metal –last a life time, but require anticoagulant therapy for life. Also noisy (often make a loud ‘click’ sound).

There are three types of metal valve:
- Tilting disc
- Double tilting disc
- Ball in a cage

Question 14

what is the most common indication for cardiac valve surgery

Answer 14

symptomatic aortic stenosis is the most common idication

Question 15

how may a patient with severe aortic stenosis present

Answer 15

Symptomatic fluid overload (SOB/orthopnoea/peripheral oedema)

Exertional syncope

Chest pain

Question 16

what does aortic stenosis result from

Answer 16

progressive thickening and restricted opening of the aortic valve

this leads to a fixed obstruction to blood flow out of the left ventricle and around the body

Question 17

what are the two types of surgeries done

Answer 17

surgical aortic valve replacement or transcatheter aortic valve insertion (TAVI) depending in individual patient characteristics.

Question 18

what medication is given to patients with aortic stenosis

Answer 18

diuretics to improv symptoms

Question 19

A 60 year old male patient with a history of HF presents to clinic with worsening shortness of breath and increased ankle swelling over 3 months. He currently takes ramipril, bisoprolol, eplerenone and furosemide 20mg OD. His recent echo shows an ejection fraction of 35%.

Which is the most appropriate next medication to add in?

Answer 19

Ivabradine

Question 20

A 60 year old male presents to A&E complaining of fluttering in his chest for about a week and this morning woke feeling dizzy, unwell and short of breath. His pulse is irregularly irregular and CRT= 4 seconds. There are bibasal crackles on inspiration. ECG shows absent p waves and narrow QRS complexes. Obs show:

• HR 230bpm
• BP 80/44
• RR 28 Sats 93% OA
• T 37.1

Given the likely diagnosis, what is the next best step in management?

Answer 20

Synchronized DC cardioversion

Question 21

A 74 year old woman is diagnosed with paroxysmal atrial fibrillation. What is the minimum CHA2DS2VASC score indicated for anticoagulation consideration?

Answer 21

2

Question 22

A 70 year old female has a 4/52 history of fever and malaise. PMH: COPD and CCF. Observations:

• HR 80bpm
• BP 145/90
• T 38.2
• RR 18
• Loud ejection systolic murmur at sternal angle, radiates to the neck.
• Echo shows 4mm vegetation on leaflet of aortic valve.

Which additional finding is necessary to confirm the patient’s diagnosis?

Answer 22

Single positive blood culture for Coxiella burnetti