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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Angina pectoris

  • Dyspnea (left ventricular [LV] heart failure)

  • Effort syncope

  • Midsystolic murmur radiating to the carotid arteries

  • Carotid upstroke delayed in reaching its peak and reduced in amplitude (parvus et tardus)

  • Echocardiography shows thickened, immobile aortic valve leaflets

  • Doppler echocardiography quantifies increased transvalvular mean and peak pressure gradients and reduced valve area

GENERAL CONSIDERATIONS

  • Definition/description:

    • – Narrowing of the aortic valve orifice due to failure of the aortic leaflets to open fully

  • Etiology/risk factors:

    • – Aortic valve degeneration caused by inflammation, lipid accumulation, and calcification, and has same risk factor profile as atherosclerosis

    • – This pathologic process is undoubtedly related to genetic polymorphisms but can be accelerated in younger individuals with end-stage renal disease, Paget’s disease, and familial hypercholesterolemia.

    • – Rheumatic fever is less frequently a cause in the developed world and almost always occurs with mitral valve disease and has concomitant aortic regurgitation

    • – Connective tissue diseases such as systemic lupus erythematosus can also cause aortic stenosis (AS)

  • Demographics:

    • – More common in men

    • – Rheumatic AS usually clinically manifests in middle age

    • – Degenerative AS is a disease of the elderly

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Angina pectoris

  • Effort syncope

  • Dyspnea

PHYSICAL EXAM FINDINGS

  • There is a long latent period in which a basal systolic murmur can be heard that becomes more intense with time

  • Harsh, medium-pitched, midsystolic murmur heard best in the aortic area, usually grade II–IV and may be heard at the apex

  • Low-amplitude, delayed carotid artery upstroke (pulsus parvus et tardus), occasionally with a palpable shudder

  • Soft second heart sound, occasionally with reversed splitting in severe cases

  • Fourth heart sound

  • Increased amplitude and duration of apical impulse

  • Possible signs of congestive heart failure

DIFFERENTIAL DIAGNOSIS

  • Discrete subvalvular AS

  • Supravalvular AS

  • Hypertrophic obstructive cardiomyopathy

  • Pulmonic stenosis

  • Ventricular septal defect

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Occasionally hemolytic anemia seen in severe cases

  • Patients with a history of bleeding may exhibit reduced factor VIII and von Willebrand factor antigen levels

  • Natriuretic peptide levels often elevated in symptomatic patients

ELECTROCARDIOGRAPHY

  • LV hypertrophy, left atrial enlargement

EXERCISE TESTING

  • Treadmill exercise testing can be cautiously done to ascertain whether the patient is symptomatic or not

IMAGING STUDIES

  • Chest x-ray:

    • – Normal heart size with LV prominence

    • – Occasionally a dilated ascending aorta

    • – Occasionally aortic valve calcification in severe cases

  • Transthoracic echocardiography:

    • – Thickened and calcified aortic valve leaflets with reduced mobility

    • – Concentric LV hypertrophy

    • – Left atrial enlargement

  • Doppler echocardiography:

    • – Peak and mean pressure gradients across the aortic valve can by estimated by Doppler echocardiography using the simplified Bernoulli ...

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