AORTIC STENOSIS 15A
A 52-year-old man is brought to the emergency department after a syncopal episode. While running in the park, he suddenly lost consciousness. He had no premonitory symptoms and no symptoms or deficits upon regaining consciousness. For several weeks, he had had substernal chest pressure with exercise. He had no shortness of breath, dyspnea on exertion, orthopnea, or paroxysmal nocturnal dyspnea. As a child, he had had a heart murmur (never further evaluated). On examination, his blood pressure is 110/90 mm Hg, heart rate 95 beats/min, respiratory rate 15 breaths/min, and oxygen saturation 98%. The carotid pulse is weak and delayed in character. Cardiac examination reveals a laterally displaced, sustained apical impulse; a grade 3/6 midsystolic murmur, loudest at the base and radiating to the neck; and an S4 gallop. The lungs are clear. There is no lower extremity edema. Electrocardiogram shows left ventricular hypertrophy (LVH).
What are the salient features of this patient’s problem? How do you think through his problem?
Salient features: Middle age; childhood murmur; syncope without prodrome or postictal phenomena; angina pectoris; no signs of heart failure (yet); narrow pulse pressure; pulsus parvus (weak) et tardus (late); systolic murmur at the base radiating to the carotids; S4 gallop; electrocardiogram showing LVH
How to think through: With recent exertional substernal chest pressure then sudden syncope, what diagnoses are most likely? (Coronary artery disease, acute myocardial infarction (MI), transient ventricular arrhythmia.) However, the physical examination suggests valvular heart disease. The murmur’s radiation to the neck establishes this as aortic stenosis (AS) as opposed to the more common aortic sclerosis. The diminished and delayed carotid artery pulse indicates severe AS. Why does he have a laterally displaced and sustained apical impulse? (LVH caused by a high-pressure gradient across the aortic valve.) His childhood murmur suggests what predisposition to AS? (Bicuspid aortic valve.) What are the next steps in his management? (Cardiac enzymes to rule out MI; echocardiography to assess the aortic valve; consultation to discuss aortic valve replacement.)
AORTIC STENOSIS 15B
What are the essentials of diagnosis and general considerations regarding aortic stenosis?
Essentials of Diagnosis
Diminished and delayed carotid pulses (pulsus parvus et tardus)
Soft, absent, or paradoxically split S2
Harsh systolic murmur, classically crescendo–decrescendo, along the left sternal border, often radiating to the neck and sometimes associated with a thrill
Electrocardiography (ECG) with LVH; calcified valve on radiography; echocardiography is diagnostic
General Considerations
Congenital bicuspid valve is the most common etiology in middle-aged patients.
The cause in elderly patients is usually valvular degeneration from progressive calcification.
It is more frequent in men, smokers, and patients with hypercholesterolemia and hypertension.
Coronary artery disease is often coincident because risk factors are the same.
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