Aortic Stenosis

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    • Aortic stenosis
      • Etiology
        • Degenerative calcific disease (idiopathic, older population)
        • Bicuspid aortic valve (MCQ)
          • most common congenital valve abnormality
          • can result in aortic stenosis around age 40.
      • Symptoms
        • Usually asymptomatic early in course
        • Dyspnea
        • Angina and syncope (typically exertional): (MCQ)
          • Occurs particularly during exercise—peripheral resistance falls, LV pressure remains the same due to stenotic valve,
          • CO cannot maintain BP causing syncope(MCQ)
          • low BP to coronary arteries causes angina
        • Heart failure
      • Diagnosis/signs
        • Forceful apex beat with normally located PMI
        • Loud systolic ejection murmur(MCQ)
          • crescendo–decrescendo
          • medium pitched
          • loudestat 2nd R interspace
          • radiates to carotids
        • Paradoxical splitting of S2(MCQ)
        • Narrow pulse pressure(MCQ)
        • ECG may show left ventricular strain pattern.(MCQ)
        • Echocardiography demonstrates diseased valve.
        • Calcification of aortic valve may be seen on CXR.
      • Treatment
        • Avoid strenuous activity.
        • Avoid afterload reduction.(MCQ)
        • Valve replacement is definitive therapy.(MCQ)
        • Valvuloplastyproduces only temporary improvement as rate of restenosis is very high.
      • Prognosis:
        • Mean survival for patients withAS and:(MCQ)
          • Angina= 5 years
          • Syncope= 2–3 years
          • Heart failure= 1–2 years
      • Clinical pearls :
          • Left ventricular strain pattern is ST segment depression and T wave inversion in I, aVL, and left precordial leads.(MCQ)
          • Patients with aortic stenosis should be considered for valve replacement for:(MCQ)
            • Persistent symptoms
            • Aortic orifice <0.7 cm2 body surface area
            • Gradient >70 mm Hg
          • Congenital bicuspid aortic valve, usually asymptomatic until middle or old age.
          • "Degenerative" or calcific aortic stenosis;same risk factors as atherosclerosis.(MCQ)
          • Symptoms likely once the peak echo gradient is > 64 mm Hg.(MCQ)
          • Delayed and diminished carotid pulses.(MCQ)
          • Soft, absent, or paradoxically split S2.(MCQ)
          • Harsh systolic murmur, sometimes with thrill along left sternal border, often radiating to the neck; may be louder at apex in older patients.(MCQ)
          • ECG usually shows LVH
          • calcified valveis seen on radiography or fluoroscopy.
          • Echocardiography/Doppler is diagnostic.(MCQ)
          • Surgery indicated for symptoms.
          • Surgical risk is typically low even in the very elderly.(MCQ)
          • Surgery considered for asymptomatic patients with severe aortic stenosis.
          • In mild or moderate cases where the valve is still pliable, an ejection click may precede the murmur.
          • Gallaverdinphenomenon(MCQ)
            • The characteristic systolic ejection murmur is heard at the aortic area and is usually transmitted to the neck and apex.
            • In some cases, only the high-pitched components of the murmur are heard at the apex, and the murmur may sound like mitral regurgitation (so-called Gallaverdin phenomenon)
          • In severe aortic stenosis(MCQ)
            • apalpable LV heave or thrill
            • aweak to absent aortic second sound
            • reversed splitting of the second sound is present
          • When the valve area is less than 0.8–1 cm2 (normal, 3–4 cm2), ventricular systole becomes prolonged and the typical carotid pulse pattern of delayed upstroke and low amplitude is present(MCQ)
          • LVH increases progressively, with resulting elevation in ventricular end-diastolic pressure
          • Cardiac output is maintained until the stenosis is severe (with a valve area < 0.8 cm2).(MCQ)
          • Syncope (MCQ)
            • typicallyexertional and a late finding.
            • Syncope occurs with exertion as the LV pressures rises, stimulating the LV baroreceptors to cause peripheral vasodilation.
            • This vasodilation results in the need for an increase in stroke volume, which increases the LV systolic pressure again, creating a cycle of vasodilation and stimulation of the baroreceptors that eventually results in a drop in BP, as the stenotic valve prevents further increase in stroke volume
          • A BNP > 550 pg/mL has been associated with a poor outcome in these patients regardless of the results of dobutamine testing.(MCQ)


      Aortic Stenosis Explained Clearly!
      Understand aortic stenosis with this clear explanation from Dr. Roger Seheult.
      Includes discussion of heart anatomy, pathophysiology, heart sounds and murmurs, valves, symptoms, atrial fibrillation, cardiac output, LVH, pulse pressure, paradoxical splitting of the second heart sound, and treatment.
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      This video is one of four describing aortic stenosis, and is geared towards health care professionals. The purpose of these videos is to provide information on aortic stenosis, its symptoms, diagnosis and treatment for primary care physicians.
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      his video is one of four describing aortic stenosis, and is geared towards healthcare professionals. The purpose of these videos is to provide information on aortic stenosis, its symptoms, diagnosis and treatment for primary care physicians.
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      This video is one of four describing aortic stenosis, and is geared towards healthcare professionals. The purpose of these videos is to provide information on aortic stenosis, its symptoms, diagnosis and treatment for primary care physicians.
      Treating Aortic Stenosis
      This video is one of four describing aortic stenosis, and is geared towards healthcare professionals. The purpose of these videos is to provide information on aortic stenosis, its symptoms, diagnosis and treatment for primary care physicians.