Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ KEY FEATURES +++ ESSENTIALS OF DIAGNOSIS ++ Elevated systolic blood pressure in the upper extremities (always in right arm) Normal systolic blood pressure in lower extremities (often in left arm) Radial–femoral pulse delay Left ventricular prominence, "3" sign, rib notching on chest radiograph Coarctation visible by imaging Distal aortic pressure decrease by Doppler echocardiography or catheterization +++ GENERAL CONSIDERATIONS ++ Male predominance Most commonly located distal to the left subclavian artery Associated with a bicuspid aortic valve 70% of the time Usually diagnosed in childhood by routine physical examination Symptoms may arise during the second and third decades of life – Coarctation should be suspected in the patient in his 20s or 30s presenting with hypertension Seen in more than 10% of patients with Turner’s syndrome Early detection and repair are important to forestall the accelerated development of coronary artery disease and congestive heart failure +++ CLINICAL PRESENTATION +++ SYMPTOMS AND SIGNS ++ Usually asymptomatic Nonspecific symptoms: – Exertional dyspnea – Headache – Epistaxis – Leg fatigue Hemorrhagic cerebrovascular accidents Endarteritis Possible congestive heart failure in the adult with longstanding hypertension related to coarctation or difficult-to-control hypertension Aortic rupture or dissection Aortic aneurysm due to poststenotic dilatation Infective endocarditis of an associated bicuspid aortic valve +++ PHYSICAL EXAM FINDINGS ++ Elevated systolic blood pressure in the right arm Reduced systolic blood pressure in the legs Radial–femoral pulse delay Palpable intercostal arteries (collaterals) Brisk carotid upstroke Hyperdynamic left ventricular impulse Late systolic murmur between the scapulae to the left of the spine Ejection click and systolic ejection murmur (with or without diastolic murmur of aortic insufficiency) with associated bicuspid aortic valve +++ DIFFERENTIAL DIAGNOSIS ++ Other causes of systemic hypertension Aortoiliac disease +++ DIAGNOSTIC EVALUATION +++ LABORATORY TESTS ++ No specific studies +++ ELECTROCARDIOGRAPHY ++ ECG findings: – Left ventricular hypertrophy – Left atrial enlargement – Atrial fibrillation +++ IMAGING STUDIES ++ Chest x-ray: – Rib notching – "3"sign (dilated left subclavian artery and dilated distal aorta forming the upper and lower curvatures, respectively) – Left ventricular and left atrial enlargement Echocardiography: – Precordial 2-dimensional echocardiogram from the suprasternal notch may reveal the coarctation – Color-flow Doppler acceleration in the descending aorta with persistent diastolic forward flow Magnetic resonance angiography/CT: – Can localize and define the extent of narrowing with a high degree of accuracy – Also used for postoperative evaluation +++ DIAGNOSTIC PROCEDURES ++ Cardiac catheterization (rarely necessary): – When noninvasive imaging cannot fully define the anatomy – When concomitant coronary artery disease is suspected +++ TREATMENT +++ CARDIOLOGY REFERRAL ++ When aortic ... Your MyAccess profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth