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Bates Treatment Options in Severe Aortic Stenosis 357
| Content Provider | Semantic Scholar |
|---|---|
| Author | Bates, Eric R. |
| Copyright Year | 2011 |
| Abstract | Case presentation: An 80-year-old woman is referred for cardiovascular evaluation because of a systolic murmur. She denies symptoms of angina, syncope, or heart failure. The physical examination and echocardiogram are consistent with severe aortic stenosis (AS). What further evaluation is indicated? Aortic stenosis is becoming more frequent as the average age of the population increases; it affects up to 5% of the elderly population.1 The diagnosis of severe AS is most easily defined by Doppler echocardiography with maximum aortic jet velocity 4.0 m/s, mean transvalvular pressure gradient 40 mm Hg, and continuity equation valve area 1.0 cm or valve area index 0.6 cm (Figure 1).2 However, when cardiac output is low, a lower transvalular gradient and jet velocity may be present. Echocardiography is also used in patients with AS to assess left ventricular hypertrophy, size, and function; left atrial size, and the presence of pulmonary hypertension or other associated valvular disease. Nevertheless, the decision to proceed with aortic valve replacement (AVR) is usually based on the presence of symptoms. So, if this patient really is asymptomatic, the echocardiographic criteria for severe AS would not automatically result in a cardiac surgery referral.3–5 The 1%/y risk of sudden death in asymptomatic patients with AS is not higher than that of historical controls without AS.5 However, because patients may deny or fail to recognize symptoms or avoid them by decreasing physical activity, exercise testing can be useful in asymptomatic patients to confirm that the patient really is symptom free. Exercise-induced symptoms, ventricular tachycardia, or hypotension predict a short symptom-free survival and an increased mortality risk.6,7 Asymptomatic patients with severe AS not referred for AVR should be monitored frequently for change in exercise tolerance, exertional chest discomfort, dyspnea, lightheadedness, or syncope. An annual echocardiogram should be performed to evaluate disease progression in patients with severe AS. The higher the maximum aortic jet velocity, the more likely they are to require AVR within 5 years.3,8 An annual increase in aortic jet velocity 0.3 m second 1 year 1 or a decrease in valve area 0.1 cm/y indicates rapid hemodynamic progression. Concomitant coronary artery disease or moderate/severe aortic valve calcification are associated with rapid hemodynamic progression.4 Conditions in which early AVR may be warranted in the absence of symptoms, include very severe AS (maximum jet velocity 5.0 m/s, mean gradient 60 mm Hg, or aortic valve area 0.6 cm), left ventricular ejection fraction (LVEF) 0.50, abnormal exercise test result, markedly calcified aortic valve, rapid progression of AS by Doppler criteria, or expected delays in the diagnosis or treatment of disease progression.2 Clinical judgment is particularly required in the elderly to balance the risk of waiting for disease progression and operating when the patient is older versus operating earlier when surgical risk may be lower. Medical treatment options are limited. Systemic arterial hypertension should be treated cautiously and hypotension avoided. Routine endocarditis antibiotic prophylaxis is no longer recommended. Although the active valvular disease process is characterized by lipid accumulation, inflammation, and calcification, statin therapy does not reduce disease progression in patients with severe AS.9 |
| File Format | PDF HTM / HTML |
| Alternate Webpage(s) | http://circ.ahajournals.org/content/circulationaha/124/3/355.full.pdf?download=true |
| Language | English |
| Access Restriction | Open |
| Content Type | Text |
| Resource Type | Article |
