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Aortic Stenosis

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Slide 1 :

AORTIC STENOSIS A Review for the Internist,Hospitalist, and Family Physician R.B.Whiting,MD,MACP,FACC

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C D

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VALVULAR AORTIC STENOSIS Congenital Acquired Rheumatic Degenerative(age related) Atherosclerotic Calcific AS associated with Paget’s Disease, end-stage renal failure, rheumatoid arthritis, etc.

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AORTIC SCLEROSIS Irregular thickening of the valve leaflets seen on echo but without significant obstruction. May result in a systolic ejection murmur. Approx. 25% over age 65 and over 40% over 85 Evidence suggests Ao sclerosis does progress to degenerative aortic stenosis.

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AORTIC SCLEROSIS Cosmi et al studied 2000 pts with aortic sclerosis and found 16% progressed to aortic stenosis and 10% had mild, 3% moderate, and 2% severe obstruction. The average time for progression from ao sclerosis to severe stenosis was 8 years. Arch Int Med 2002; 62:2345

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Degenerative Aortic Stenosis Most common type of AS today and the usual cause for aortic valve replacement Shares common risk factors with mitral annular calcification Risk factors for calcific aortic stenosis are similar to those for vascular atherosclerosis

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AORTIC STENOSIS NATURAL HISTORY May be asymptomatic for many years Gradual onset and slow progression LVH allows large gradient to be tolerated for years with little or no reduction of cardiac output, left ventricular dilatation, or symptoms

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AORTIC STENOSIS Obstruction is progressive-but insidious Rate of progression is variable so difficult to predict in an individual patient On average: AVA decreases 0.12 cm2/yr with average increase jet velocity of 0.32 m/sec per year and mean gradient increase of 7 mm Hg per year

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AORTIC STENOSIS Critical obstruction is associated with: Peak gradient >50 mm Hg in presence of normal output Effective oriface area <0.8 cm2 Normal ao valve area=2.6-3.5 cm2

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AORTIC STENOSIS In general: Mild Aortic Stenosis=1.5-2.0 cm2 Moderate Stenosis=1-1.5 cm2 Severe Aortic Stenosis=<1.0 cm2 Critical Aortic Stenosis=<0.8 cm2

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AORTIC STENOSIS Thickening and stiffening of the LV in the face of increasing obstruction results in Increased LVEDP Result=LAH and diastolic dysfunction Left atrium becomes critical in filling the ventricle and At Fib or AV dissociation are poorly tolerated

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AORTIC STENOSIS In significant ao stenosis, the cardiac output may be fairly well maintained at rest but fails to augment with exercise Late in the course of severe AS : cardiac output, stroke volume, and the gradient itself all decline……while the Mean LA pressure, capillary wedge pressure and P.A. pressure increase

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AORTIC STENOSIS DIAGNOSIS: Symptoms Physical exam Chest X-Ray EKG Echo-major diagnostic tool and means of follow-up. Allows measurement of gradient, LV function, associated lesions

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AORTIC STENOSIS Symptoms: Can be asymptomatic Dyspnea on exertion Angina Syncope or “light spells” Palpitations not listed as major symptom, but common in significant heart disease

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AORTIC STENOSIS Implications of symptoms With unrelieved obstruction survival is approx 2 years after onset of failure, 3 years after onset of syncope, and 5 years after onset of angina Recent data: symptomatic pts with severe stenosis-average survival was 2 years with only 20% survival at 5 yrs

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AORTIC STENOSIS Physical Exam Narrow pulse pressure, slow arterial upstroke, carotid shudder Sustained PMI and with failure it is displaced laterally and inferiorly S4 common, S1 soft, S2 may be single, systolic ejection murmur best at the base

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AORTIC STENOSIS MANAGEMENT Medical: medications and careful follow-up Surgical: Valve replacement is the best approach in most cases

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AORTIC STENOSIS Medical Management Patient education Medications-patients with associated hypertension or CHF can be treated with medications if AS is mild or moderate. Caution if Severe AS, especially with beta blockers and dilator type agents Favor use of statin drugs

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AORTIC STENOSIS Management-2 Periodic echo-if mild AS: echo every 2 years; for moderate AS every year, and for severe AS echo assessment every 6-8 months Question the role of SBE prophylaxis

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AORTIC STENOSIS Management-3 (surgical and related) Non-calcified congenital AS can be managed with open commissural incision at low risk Some cases of adult AS can be managed by Balloon Valvuloplasty- often will need operative care in 2 yrs Most adult calcific AS if severe or progressive-symptomatic best care is AVR

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AORTIC STENOSIS Management-4 AVA <1.0 cm2 whose symptoms are believed to result from the stenosis Asymptomatic patients if progressive LV dysfunction, or if hypotensive response to exercise Threshold for AVR will likely lower in the future

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AORTIC STENOSIS Effects of successful AVR Substantial clinical and hemodynamic improvement Ten year survival approx 85% Exertional dyspnea improved as also frequency and severity of angina Impaired LV performance improves toward normal often and LV mass decreases toward normal-not normal

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AORTIC STENOSIS SUMMARY: Aortic stenosis of varying degree is common in adults Diagnosis and management are DEPENDENT on the internist, hospitalist, and family physician Follow up involves history, physical, and especially the echo-Doppler Valve replacement=best overall Rx

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Mild Aortic Stenosis=1.5-2.0 cm2; Moderate Stenosis=1-1.5 cm2SUMMARY: Aortic stenosis of varying de more Mild Aortic Stenosis=1.5-2.0 cm2; Moderate Stenosis=1-1.5 cm2SUMMARY: Aortic stenosis of varying degree is; common in adults; Diagnosis and management less

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