Term
presenting an elderly man with AS
The physical signs are |
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Definition
Low volume pulse (regular/rate controlled AF)
high pitched loud ESM audible throughout precordium and loudest in aortic area. Radiates to carotids
Negatives:
No signs of IE, Pulm HTN or HF
Comment on apex beat
Signs of severe AS - significant gradient across valve:
quiete S2
long duration of murmur
low volume pulses
forceful apex beat |
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Term
| how to investigate patient with AS |
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Definition
ECG - evidence of LVH
ECHO - to assess valve area, gradient across valve and LVFx
Normal aortic valve area is 3-4cm^2
Severe AS is defined by a peak velocity >4 m/sec, an MPG (mean pressure gradient) >40 mmHg and an AVA (aortic valve area) <1 cm² |
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Term
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Definition
Aortic stenosis
Aortic sclerosis
Hyper obstructive cardiomyopathy |
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Term
| You heard an ESM. What if this was PSM? |
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Definition
| If PSM i would consider Mitral regurgitation (although characters are different to ESM. They are heard at different sites and MR would radiate to axilla) AS can be heard through the precordium but would not radiate to the axilla, instead to the carotids. |
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Term
| ESM heard. Why is this not pulmonary stenosis than AS? |
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Definition
Site of murmur would be different and I would expect to hear pulmonary stenosis loudest over pulmonary area
I would expect there to be a right ventricular heave
I might expect a different demographic of patient, such as a younger patient.
I would expect pulmonary stenosis to be louder on inspiration whereas AS is louder on expiration as a left sided murmur. |
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Term
You have performed an ECG and ECHO
ECG shows rate controlled AF
ECHO shows severe AS: AVA 0.9cm and good LV function. How would you manage this patient |
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Definition
ECHO confirms severe AS.
We know he is symptomatic with breathlessness
I would take a history and find out if he had any:
angina
syncope
HF symptoms
Any symptoms in the context of severe AS would prompt a referral to the surgeons for consideration of AVR |
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Term
| Whilst waiting for referral to surgeons what medical management of AS are you familiar with? |
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Definition
Beta blockers are mainstay
Some important drugs to avoid in AS include
Vasodilators (they can increase the gradient across the valve)
ACE-inhibitors
Nitrates
Sildenafil |
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Term
| What surgical options are you aware of for management of symptomatic severe AS |
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Definition
Mechanical AV - more durable and lasts longer but does require life long anticoagulation (might suit if patient is in AF)
Tissue valve - not as durable but does not require lifelong anticoagulation
Trans-aortic valve intervention (TAVI) - appropriate for those patients not fit for surgical intervention. |
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Term
| What evidence to look for in severe AS |
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Definition
slow rising pulse
narrow pulse pressure
muted or absent second heart sound
pitch of murmur (high) and duration (long)
Radiation to carotids
evidence of LV heave
You may find a 4th HS in patients with significant LVH |
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Term
| What clinical signs might you expect where the predominant legion is of aortic regurgitation? |
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Definition
Collapsing pulse
wide pulse pressure
hollow diastolic murmur heard throughout diastole
Apex beat may be thrusting and displaced. |
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