Aortic stenosis (Complete*) Flashcards by Sydney Carrera-Brown

Define aortic stenosis

Type of aortic valve disease characterised by pathological narrowing of the aortic valve leading to blood flow obstruction.

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List 6 causes of aortic stenosis.

Age-related calcification

Bicuspid aortic valve

Rheumatic heart disease

William’s syndrome

Supra-valvular aortic stenosis

Subvalvular aortic stenosis

HOCM

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

Calcification

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What cause of aortic stenosis is most common in under 65 year olds?

Bicuspid aortic valve

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What inherited condition causes supra-valvular aortic stenosis?

Williams syndrome

N.B. Have supravalvular aortic narrowing

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What inherited condition causes sub-valvular aortic stenosis?

Hypertrophic cardiomyopathy

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What are some risk factors for aortic stenosis? (4)

Age > 60 years

Congenital bicuspid valve

Rheumatic heart disease

Chronic kidney disease (speeds up calcification)

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What are the main signs/symptoms of aortic stenosis? (11)

Classic triad of symptoms:

Exertional dyspnoea

Most common initial complaint
Reduced execise tolerance and increased fatigability

Exertional angina

50% of these patients have additional IHD

Exertional syncope/pre-syncope

Present in severe stenosis

Additional features

Left-sided HF symptoms (e.g. paroxysmal nocturnal dyspnoea)
Palpitations

Signs:

Ejection systolic murmur

Radiates to carotids
Louder on expiration and leaning forwards

In severe stenosis:

Slow rising carotid pulse

Narrow pulse pressure

Soft/absent S2

Thrill

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What is the earliest clinical presentation of aortic stenosis?

Exertional dyspnoea

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What are the characteristic features of murmurs heard in aortic stenosis?

Ejection systolic murmur

Tends to radiate to the carotid artery

Louder on expiration and when leaning forwards

Murmur is decreased following valsalva maneouvre

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An ejection systolic murmur that gets louder with valsava maneouver and quiter when squatting is more indicative of what cause?

N.B. Think its louder with valsalve and quieter with squatting

Hypertrophic cardimyopathy (sub-valvular aortic stenosis)

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What symptoms/signs are indicative of severe aortic stenosis? (7)

Exertional syncope/presyncope

Narrow pulse pressure

Slow rising pulse

Delayed ejection systolic murmur

Soft/absent S2

S4 (reverse splitting of S2)

Aortic valve closes after pulmonary valve

Thrill

Left ventricular hypertrophy or failure (e.g. displaced apex beat)

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What are the characteristics of a pulse felt in patients with severe aortic stenosis?

Slow rising pulse with narrow pulse pressure

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What heart sounds may be heard in patients with severe aortic stenosis?

Silent S2

S4 (Reverse splitting of S2)

N.B. Aortic valve closes after pulmonary valve (due to the longer time required for blood to exit the left ventricle)

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What complications are associated with AS?

Heart failure

Arrythmia

SCD

Heye’s syndrome (GI bleeding)

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What is Heyde’s syndrome?

Triad of:

Aortic stenosis
GI bleed
Coagulopathy

N.B. Von Willebrand multimers get sheared across the narrowed aortic valve. This prevents them from mediating platelet adhesion at sites of angiodysplasia in the intestine.

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What complication is most associated with bicuspid aortic valves?

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Endocarditis

What are the main investigations performed in patients suspected of having aortic stenosis? (3)

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Bedside:

ECG

May show left ventricular hypertrophy

Imaging/Invasive:

Echocardiogram

Confirm diagnosis and check for HF complications

CXR:

Check for cardiomegaly or pulmonary congestion

What investigation is diagnostic for aortic stenosis?

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Echocardiogram

What ECHO findings are indicative of severe aortic stenosis?

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Peak gradient >40 mmHg

N.B. if severe LV dysfunction a low peak gradient can be falsely reassuring

Valve area < 1 cmx2

Aortic jet velocity >4 m/s

What investigations are used to assess severity of aortic stenosis following confirmation of diagnosis?

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Bloods:

BNP

Assess for HF and predict timing for intervention in assymptomatic patients

Imaging:

Exercise testing

For assymptiomatic physically active patients with severe stenosis to elicit symptoms

Multi-slice computed tomography (MSCT):

Assess calcification to determine calcium score for severity of AS

Cardiac MRI

Quantify fibrosis

When should a 2 week urgent referal to a specialist (alongside echocardiography) be considered in patients suspected of aortic stenosis?

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Adults with a systolic murmur and exertional syncope.

Murmur and severe symptoms (angina or breathlessness on minimal exertion or at rest)

What is the management plan for patients who are asymptomatic with mild AS and no risk factors?

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Conservative:

Serial testing (e.g. ECHO, BNP)

Mild-moderate: Yearly
Severe AS: 6-monthly

Managing HF, BP and maintaining sinus rhythm

How often should patients with mild/moderate AS be monitored if on conservative management?

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Yearly

How often should patients with severe AS be monitored if on conservative management?

6-monthly

What is the management plan for symptomatic patients diagnosed with aortic stenosis?

**_Surgical_**: Definitive management: Valvular repair * Surgical valvular repair * Transcatheter aortic valve implantation (TAVI) **_Medicine_**: Management of HF, HTN, Arryhthmias **_Other_** Balloon valvuloplasty: * For palliative management or critically unwell * In children and young adults with congenital AS

What medication is contraindicted in patients with severe AS?

ACE inhibitors ## Footnote N.B. Leaves aortic systemic pressure low

What is the definitive management plan for AS?

Valvular repair

When is valvular repair indictaed?

Either of the following: AS with symptoms or exercise stress test induced symptoms Assymptomatic with any of the following: * LVEF < 55% * Markedly elevated BNF without other explanation * Severe pulmonary hypertension > 60mmHg * Severe calcification and peak velocity progression _>_ 0.3m/s^2 * Aortic peak velocity > 5m/s^2 * Aortic valve area less than 0.6 cm2 * Undergoing other cardiac surgery (e.g. CABG)

What are the two main options for aortic valve replacement? When would you choose one option over the other?

Surgical aortic valve replacement (SAVR) * Patients who are low risk and < 75 years of age. Transcatheteric aortic valve implantation (TAVI): * Used for patients with a high operative risk (e.g. elderly)

What additional investigations are performed prior to surgical aortic valvular replacement (SAVR)>

**Angiogram** * Identify other cardiovascular disease so that surgical procedures can be combined into one **MSCT** * Assess the anatomy to aid with procedure **TOE** * Assess for endocarditis and mitral valve disease * Monitoring TAVI procedure

What are the three main types of valves used in repairs?

Metallic valve Tissue valve Synthetic valve (via TAVI)

What are the pros and cons of metallic valve

Pros: * Lifelong and lower risk of reoperation Cons: * Lifelong anticoagulation with warfarin * Clicking sound

Metallic valves are most suitable for which type of patients?

Young patients

Patients with metallic valve replacement should be anticoagulated with which medication?

Warfarin INR target of 2-3

What are the pros and cons of tissue valves?

Pros * Doesnt require anticoagulation Cons * Will wear out over 15-20 years (higher lifetime reoperation risk)

Which patients benefit most from bioprosthetic/tissue valves?

Elderly patients or patients with limited life expectancy

What are the pros and cons of synthetic valves?

Pros: * Minimally invasive procedure * Less post-op complications and shorter recovery * Useful for patients too sick/frail for surgery Cons: * Not lifelong

Is the presence of an ejection systolic murmur post valve repair always pathological?

No as prosthetic valve can cause turbulent blood flow ## Footnote N.B. If early-diastolic should worry about prosthetic valve degeneration

Aortic stenosis (Complete*) Flashcards

(40 cards)