AORTIC STENOSIS

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

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

4. 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.

5. 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 AORTIC SCLEROSIS

6. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

15. 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

16. 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

17. 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

18. 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

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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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