Aortic stenosis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]; Rim Halaby, M.D. [3]

Aortic Stenosis Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
General Approach
Choice of Intervention
Type of Valve and Discharge Anticoagulation Therapy
Do's
Don'ts

Overview

Aortic stenosis is the progressive narrowing of the diameter of the aortic valve (normal valve area is 3 - 4 cm²). The symptoms are caused by a decrease in the stroke volume which reduces blood flow to peripheral tissues. The most common etiology of aortic stenosis is calcific aortic valve disease. The management of aortic stenosis depends on the stage of the disease which is determined by whether the patient is symptomatic or asymptomatic, the area of the valve, and the hemodynamic consequences of the stenosis.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Aortic stenosis is a progressive disease and does not have a life threatening cause.

Common Causes

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[1]
Boxes in the red signify that an urgent management is needed.

Abbreviations: AVR: Aortic valve replacement; CK-MB: Creatine kinase myocardial type; ECG: Electrocardiogram; NSTEMI: Non ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction; TTE: Transthoracic echocardiography

 
 
 
 
 
 
Identify cardinal findings that increase the pretest probability of aortic stenosis

Systolic ejection murmur
❑ Crescendo-decrescendo
❑ Associated with an ejection click
❑ Best heard at the upper right sternal border
❑ Bilateral radiation to the carotid arteries
❑ Increases with squatting and expiration
❑ Decreases with valsalva maneuver

Pulsus parvus et tardus (a weak and slow upstroke of the carotid waveform is an excellent indicator of aortic stenosis severity)

Narrow pulse pressure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following findings require urgent management?
Tachycardia
Hypotension
Severe dyspnea
Loss of consciousness
Chest pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed to the
complete diagnostic approach below
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The patient has a condition that exacerbates AS
 
 
 
 
 
The patient has a decompensated AS causing complications
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Suspect if there are palpitations
❑ Order an ECG immediately looking for
❑ Irregularly irregular rhythm, and
❑ Absent P waves
 

❑ Suspect if there is severe chest pain
❑ Order an ECG immediately

❑ Order troponin and CK-MB

 

❑ Suspect if there is loss of consciousness of:
❑ Short duration
❑ Rapid onset
❑ Complete spontaneous recovery
 

❑ Suspect if there are:
❑ Severe dyspnea
❑ Signs of volume overload
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Treat the complications of aortic stenosis that lead to decompensation
❑ Order a TTE to evaluate the severity of the aortic stenosis
❑ Do not give nitrates (could cause severe hypotension)
❑ Monitor vital signs continuously
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient improve with medical therapy?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed with urgent AVR
 
 



Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[1]

Abbreviations: AS: Aortic stenosis; AF: Atrial fibrillation; AVR: Aortic valve replacement; CXR: Chest X-ray; ECG: Electrocardiogram; LBBB: Left bundle branch block; LVH: Left ventricle hypertrophy; TAVR: Transcatheter aortic valve replacement; TTE: Transthoracic echocardiography; VHD: Valvular heart disease

 
 
 
 
Characterize the symptoms:

Chest pain, angina-type pain (Left untreated, the average survival is 5 years after the onset of angina in the patient with AS)

❑ The pain is crushing, squeezing, pressure or tightness in nature
❑ The pain increases with exercise, relieved with rest
❑ Pain under the chest bone, it may move to other areas

Syncope (Left untreated, the average survival is 3 years after the onset of syncope in the patient with AS)
❑ Symptoms suggestive of congestive heart failure (Left untreated, the average survival is 1 years after the onset of heart failure in the patient with AS)

Dyspnea on exertion
Fatigue
Orthopnea
Paroxysmal nocturnal dyspnea
Pulmonary edema
Pulmonary hypertension that can lead to:
Right ventricular failure
Hepatomegaly
Atrial fibrillation
Peripheral edema
Tricuspid regurgitation

Palpitations

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inquire about past medical history:
Cardiovascular disease
Hypertension
Bicuspid aortic valve
Rheumatic fever
Pulmonary disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Vitals
Heart rate

❑ Normal rhythm and rate (in most cases)
❑ Irregularly irregular rhythm (suggestive of AF in late stage disease)

Blood pressure

Narrow pulse pressure (<25 mmHg)
❑ Mild hypertension in moderate stenosis
Hypotension in severe stenosis

❑ Respiratory rate

❑ Normal in most cases
Tachypnea (suggestive of HF)


Cardiovascular examination
Cardiac palpation

Apical impulse (suggestive of LVH)
Palpable thrill

❑ Pulses

Pulsus parvus et tardus
Pulsus bisferiens (suggestive of mixed aortic stenosis and regurgitation)

Cardiac auscultation

Murmur
❑ Crescendo-decrescendo systolic ejection murmur with ejection click
❑ Best heard at the upper right sternal border
❑ Bilateral radiation to the carotid arteries
❑ Murmur increases with squatting and expiration
❑ Murmur decreases with valsalva maneuver

Click on the video below to listen to an aortic stenosis murmur.


Heart sounds
❑ Normal S1
Paradoxical splitting of S2 (in severe disease)
S3 (suggestive of LVH)


Respiratory examination
Rales (suggestive of congestive heart failure)


Extremities
Peripheral edema (suggestive of congestive heart failure)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order tests:

TTE (most important evaluation test) (Class I; Level of Evidence: B)

Assess the following:
❑ Valve morphology
❑ Pressure gradient
Aortic valve area
Ejection fraction
Left ventricle wall thickness and motility

ECG (shows non-specific findings):

LVH
Left atrium enlargement
LBBB
AF (in late disease)

Chest X-ray:

Cardiomegaly
Valve calcification
❑ Dilatation of ascending aorta
Pulmonary congestion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Classify aortic stenosis based on the following findings on TTE:
❑ Valve area (cm²)
❑ Transvalvular pressure gradient (mmHg)
❑ Aortic Vmax (m/s)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No stenosis

❑ Valve area 2.5-3.5 cm²
❑ No pressure gradient across the valve
❑ Aortic Vmax <2 m/s
 
Mild stenosis

❑ Valve area 1.5-2.5 cm²
❑ Pressure gradient ≤ 25 mmHg
❑ Aortic Vmax 2.0-2.9 m/s
 
Moderate stenosis

❑ Valve area 1.0-1.5 cm²
❑ Pressure gradient 25-40 mmHg
❑ Aortic Vmax 3.0-3.9 m/s
 
Severe stenosis

❑ Valve area ≤ 1.0 cm²
❑ Pressure gradient ≥ 40 mmHg
(except for stages D2 and D3, low flow low gradient)
❑ Aortic Vmax ≥ 4 m/s
 
 
 
 

Treatment

Indications for Aortic Valve Replacement

Shown below is an algorithm depicting the indications for aortic valve replacement (AVR). If the patient does not meet any of the decision pathways in the algorithm, regular monitoring is recommended and AVR is not indicated.[1]

Abbreviations: AVR: Aortic valve replacement; LVEF: Left ventricular ejection fraction; ΔPmean: mean pressure gradient; Vmax: maximum velocity

 
 
 
 
 
 
 
 
 
 
 
Abnormal aortic valve
AND
Reduction in systolic opening
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe aortic stenosis:
Vmax≥4m/s
AND
ΔPmean≥40 mmHg
 
 
 
 
 
 
 
 
 
 
Vmax3-3.9 m/s
AND
ΔPmean20-39 mmHg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the patient symptomatic?
 
 
 
 
 
 
 
 
 
 
Is the patient symptomatic?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
(Stage D1)
 
 
 
 
 
No
(Stage C)
 
 
 
Yes
 
 
 
No
(Stage B)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
LVEF <50%
(Stage C2)
 
 
 
 
Is LVEF <50%?
 
 
 
The patient is undergoing
another cardiac surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The patient is undergoing
another cardiac surgery
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vmax≥5m/s
AND
ΔPmean≥60 mmHg
(Very severe stage C1)
AND
Low surgical risk
 
 
Dobutamine stress echocardiography:
Aortic valve area ≤1 cm2
AND
Vmax≥4 ms
(Stage D2)
 
Aortic valve area ≤1 cm2
AND
LVEF ≥50%
(Stage D3)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abnormal exercise treadmill test
 
 
 
 
 
 
 
The symptoms are likely
the result of the aortic stenosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ΔVmax>0.3 m/s/y
AND
Low surgical risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
AVR (Class I)
 
AVR (Class IIa)
 
AVR (Class IIb)
 
AVR (Class IIa)
 
AVR (Class IIa)
 
AVR (Class IIa)

Choice of Intervention

Shown below is a table summarizing the choice of aortic valve replacement among patients with aortic stenosis based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease [1]

Choice of AVR Indications
Surgical AVR - Low or intermediate surgical risk

(Class I; Level of Evidence: A)

Tansthoracic aortic valve replacement (TAVR) - Prohibitive surgical risk and a predicted post-TAVR survival >12 month (Class I; Level of Evidence: B)

- High surgical risk (Class IIa; Level of Evidence: B)

Evaluation of Surgical and Interventional Cardiac Risk

Shown below is a table to assess the surgical and interventional risk which combines the Society of Thoracic Surgeons (STS) risk estimate, frailty, major organ system dysfunction and procedure-specific impediments.[1]

STC Predicted Risk of Mortality Score[2] Frailty* Major organ system compromised without postoperative improvement Specific procedural impediment**
Low risk
(Must meet ALL criteria in this row)
<4% None None None
Intermediate risk
(Must meet ANY criteria in this row)
4% to 8% 1 index (mild) 1 organ system Possible
High risk
(Must meet ANY criteria in this row)
>8% ≥2 indices (moderate to severe) No more than 2 organ systems Possible
Prohibitive risk
(Must meet ANY criteria in this row)
>50% of predicted risk of death or major morbidity at 1 year >50% of predicted risk of death or major morbidity at 1 year ≥3 organ systems Severe

*Seven frailty indices: Katz Activites of Daily Living (self-sufficient in feeding, bathing, dressing, transferring, toileting, and urinary continence) and self-sufficient in deambulation (no walking aid or assist required or 5-meter walk in <6 s).
**Examples of specific procedural impediment: tracheostomy present, heavily calcified ascending aorta, chest malformation, arterial coronary graft adherent to posterior chest wall or radiation damage.

Type of Valve and Discharge Anticoagulation Therapy

Abbreviations: AVR: Aortic valve replacement; INR: International normalized ratio; TAVR Tansthoracic aortic valve replacement

 
 
 
 
 
 
Determine:
Age
Contraindications for anticoagulation
❑ Major bleeding diathesis or coagulopathy
❑ Uncontrolled severe hypertension (systolic blood pressure >200 mmHg)
❑ Recent head trauma
❑ Platelet count < 100 000
Pregnancy
❑ Hypersensitivity to warfarin
Hemorrhagic stroke
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Patients ≤ 60 years old
AND
❑ No contraindication for anticoagulation (Class IIa; Level of Evidence: B)
 
❑ Patients 60 - 70 years old
AND
❑ No contraindication for anticoagulation
 
❑ Patients ≥ 70 years old (Class IIa; Level of Evidence: B)
OR
❑ Patients at any age AND contraindications for anticoagulation therapy (Class I; Level of Evidence: C)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bioprosthesic
OR
Mechanical prosthesis (Class IIa; Level of Evidence: B)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mechanical prosthesis
Avoid the use of direct thrombin inhibitors or anti-Xa agents in patients with mechanical prosthesis (Class III; Level of Evidence: B)
 
 
 
 
 
Bioprosthesis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have risk factors for thromboembolism†?
 
 
 
 
 
Surgical AVR
OR
TAVR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
Surgical AVR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer for long term:
Warfarin to achieve INR of 3.0 (Class I; Level of Evidence: B)
AND
Aspirin 75-100 mg/d (Class I; Level of Evidence: A)
 
Administer for long term:
Warfarin to achieve INR of 2.5 (Class I; Level of Evidence: B)
AND
Aspirin 75-100 mg/d (Class I; Level of Evidence: A)
 
Administer
Warfarin to achieve INR of 2.5 for 3 months (Class IIb; Level of Evidence: B)
AND
Aspirin 75-100 mg/d long term (Class IIa; Level of Evidence: B)
 

Administer:

Clopidogrel 75 mg/d (first 6 months) (Class IIb; Level of Evidence: C)
AND
Aspirin 75-100 mg/d (for life) (Class IIa; Level of Evidence: B)
 


†Risk factors for thromboembolism include atrial fibrillation, hypercoagulable conditions, left ventricle dysfunction, and previous thromboembolism.

Do's

Don'ts

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 Nishimura, R. A.; Otto, C. M.; Bonow, R. O.; Carabello, B. A.; Erwin, J. P.; Guyton, R. A.; O'Gara, P. T.; Ruiz, C. E.; Skubas, N. J.; Sorajja, P.; Sundt, T. M.; Thomas, J. D. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000031. ISSN 0009-7322.
  2. "Online STS Risk Calculator". Retrieved 7 March 2014.
  3. Chambers, J. (2005). "The left ventricle in aortic stenosis: evidence for the use of ACE inhibitors". Heart. 92 (3): 420–423. doi:10.1136/hrt.2005.074112. ISSN 1355-6037.
  4. Bonow, RO.; Carabello, BA.; Chatterjee, K.; de Leon, AC.; Faxon, DP.; Freed, MD.; Gaasch, WH.; Lytle, BW.; Nishimura, RA. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Unknown parameter |month= ignored (help)


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