Aortic Stenosis

Aortic stenosis (AS), or the narrowing of the aortic valve aperture, is the most common valvular heart disease. While rheumatic heart disease remains the most frequent etiology worldwide, degenerative AS and congenital bicuspid valve defect are the 2 usual causes in developed countries. Aortic stenosis gradually progresses to heart failure, producing exertional dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, angina, and/or syncope Syncope Syncope is a short-term loss of consciousness and loss of postural stability followed by spontaneous return of consciousness to the previous neurologic baseline without the need for resuscitation. The condition is caused by transient interruption of cerebral blood flow that may be benign or related to a underlying life-threatening condition. Syncope. A crescendo-decrescendo systolic murmur is audible in the right upper sternal border. Doppler echocardiography is the imaging of choice, showing structural and flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure changes in the valvular area. Valve replacement is the only effective treatment for symptomatic severe AS. Indications for the procedure depend on the patient’s symptoms, degree of AS severity, exercise tolerance, concurrent cardiac abnormalities, surgical risk, and life expectancy.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definition

Aortic stenosis (AS) is the narrowing of the aortic valve aperture.

  • Causes varying degrees of blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure obstruction between the left ventricle (LV) and the aorta
  • Consequently, produces left ventricular pressure overload
  • If left untreated, results in left ventricular dysfunction and heart failure

Epidemiology

  • Most common valvular heart disease
  • Rheumatic heart disease: most common cause of AS worldwide
  • In developed countries, most common causes are:
    • Calcific aortic valve disease
    • Congenital bicuspid aortic valve (affects 1%2% of the population)
  • Prevalence increases with age.
  • Men > women

Etiology

  • Senile calcific AS:
    • Also known as degenerative AS
    • Dystrophic calcification of the aortic valve
    • Most common cause in adults > 70 years in developed countries
    • Risk factors:
      • Hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
      • Diabetes
      • Smoking
      • End-stage kidney disease
      • Disturbances in mineral metabolism
  • Rheumatic heart disease:
    • Most common cause in the developing world
    • Often associated with mitral stenosis Mitral stenosis Mitral stenosis (MS) is the narrowing of the mitral valve (MV) orifice, leading to obstructed blood flow from the left atrium (LA) to the left ventricle (LV). Mitral stenosis is most commonly due to rheumatic heart disease. Mitral stenosis leads to impaired LV diastolic filling, increased LA pressure, and LA dilation. Mitral Stenosis
    • Presents in the 3rd to 5th decade of life
  • Congenital bicuspid aortic valve:
    • Most common congenital heart valve defect
    • More predominant in men
    • Most common cause in adults < 70 years in developed countries
    • Predisposes to early calcification and subsequent stenosis
    • Can present with other cardiac abnormalities (e.g., coarctation of the aorta Coarctation of the aorta Coarctation of the aorta is a narrowing of the aorta between the aortic arch and the iliac bifurcation commonly around the point of insertion of the ductus arteriosus. Coarctation of the aorta is typically congenital and the clinical presentation depends on the age of the patient. Coarctation of the Aorta)
  • Radiation 
  • Unicuspid valve

Pathophysiology

Mechanisms of valvular damage

  • Senile calcific AS:
    • Hemodynamic stress results in progressive valve thickening and damage, which predispose to calcification.
    • Risk factors and calcification of the leaflet bodies → aortic valve stenosis and obstruction
    • Gross morphologic hallmark: calcified masses on the outflow cusp surfaces (which limit full opening)
  • Rheumatic heart disease:
    • Inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the valve causes necrosis and injury.
    • Postinflammatory fibrosis of the valve leaflets leads to commissural fusion → calcification and stenosis
  • Bicuspid valve:
    • 2 cusps, which are often of unequal size
    • Malformed valves contribute to turbulence of blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure, which eventually leads to calcific degeneration.

Mechanism of heart failure

  • Normal aortic valve opening: cross-sectional area approximately 3–4 cm²
  • Change in gradient noted when the orifice area is < ½ of normal
  • Gradual progression of stenosis allows adaptive changes.
  • Obstruction of transvalvular blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure → increased left ventricular pressure to maintain cardiac output (CO) → Left ventricular hypertrophy (LVH) occurs, in order to overcome the increased afterload.
  • Hypertrophic left ventricle leads to decreased compliance → ↑ left ventricular end diastolic pressure (LVEDP)
  • LVH, ↑ LVEDP, and continuous valvular obstruction increase LV oxygen demand → ↑ ischemia and myocardial fibrosis
  • Changes result in decreased contractility and CO → heart failure
  • Other complications:
    • Arrhythmias (e.g., atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation)
    • Pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension (PH) or pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial pressure, which can lead to chronic progressive right heart failure. Pulmonary hypertension is grouped into 5 categories based on etiology, which include primary PAH, and PH due to cardiac disease, lung or hypoxic disease, chronic thromboembolic disease, and multifactorial or unclear etiologies. Pulmonary Hypertension
Aortic stenosis heart sounds

Image demonstrates the relationship between left ventricular pressure (green line) and aortic pressure (red line) throughout the cardiac cycle Cardiac cycle The cardiac cycle describes a complete contraction and relaxation of all 4 chambers of the heart during a standard heartbeat. The cardiac cycle includes 7 phases, which together describe the cycle of ventricular filling, isovolumetric contraction, ventricular ejection, and isovolumetric relaxation. Cardiac Cycle. The circle corresponds with the point at which the aortic valve would normally open, beginning the ventricular ejection phase. In aortic stenosis, left ventricular pressure exceeds the aortic pressure to overcome the stenotic valve. This leads to a systolic ejection murmur.

Image by Lecturio.

Clinical Presentation

Symptoms

  • Asymptomatic for years
  • Exertional dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea and fatigue (initial symptoms)
  • Classic triad (late in the course of the disease):
    1. Exertional angina or chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain (from ischemia)
    2. Syncope:
      • On exertion (exercise-induced vasodilation, under the setting of obstruction with fixed CO, leads to hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension)
      • At rest (from associated arrhythmias)
    3. Left heart failure: 
      • Orthopnea
      • Paroxysmal nocturnal dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea
      • Pulmonary edema Pulmonary edema Pulmonary edema is a condition caused by excess fluid within the lung parenchyma and alveoli as a consequence of a disease process. Based on etiology, pulmonary edema is classified as cardiogenic or noncardiogenic. Patients may present with progressive dyspnea, orthopnea, cough, or respiratory failure. Pulmonary Edema

Signs

  • Unremarkable early in the course
  • Pulse and blood pressure:
    • Narrow pulse pressure with severe AS
    • Pulsus parvus et tardus (low-amplitude (parvus), delayed (tardus) peak in the carotid arterial pulse)
  • Cardiac inspection and auscultation:
    • Hyperdynamic left ventricle leading to heave with a double or laterally displaced apical impulse
    • Heart sounds Heart sounds Heart sounds are brief, transient sounds produced by valve opening and closure and by movement of blood in the heart. They are divided into systolic and diastolic sounds. In most cases, only the first (S1) and second (S2) heart sounds are heard. These are high-frequency sounds and arise from aortic and pulmonary valve closure (S1), as well as mitral and tricuspid valve closure (S2). Heart Sounds may have:
      • Single soft S2 (aortic valve closure diminished or absent; synchronous A2P2)
      • Paradoxical splitting of S2 (pulmonic valve closure, P2, is followed by aortic valve closure, A2)
      • S4: reflects a strong atrial contraction against LVH
      • Ejection click in children and young adults (congenital AS)
    • Murmur:
      • Systolic low-pitched crescendo-decrescendo murmur heard best in the right upper sternal border and radiating to the carotids
      • Gallavardin effect: occasional downward radiation of AS murmur to the cardiac apex (may be confused with mitral regurgitation Mitral regurgitation Mitral regurgitation (MR) is the backflow of blood from the left ventricle (LV) to the left atrium (LA) during systole. Mitral regurgitation may be acute (myocardial infarction) or chronic (myxomatous degeneration). Acute and decompensated chronic MR can lead to pulmonary venous congestion, resulting in symptoms of dyspnea, orthopnea, and fatigue. Mitral Regurgitation murmur)
    • Provocative maneuvers: 
      • Decreased murmur: Valsalva maneuver, standing (decreased intracardiac volume) or sustained handgrip (increased afterload)
      • Increased murmur: leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg raising, squatting, and after a premature ventricular beat (increased preload)
Cardiac murmurs after correction

Phonocardiograms of abnormal heart sounds caused by the following cardiac defects:
aortic regurgitation Aortic regurgitation Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation, mitral valve prolapse Mitral valve prolapse Mitral valve prolapse (MVP) is the most common cardiac valvular defect, and is characterized by bulging of the mitral valve (MV) cusps into the left atrium (LA) during systole. Mitral valve prolapse is most commonly due to idiopathic myxomatous degeneration. Patients are typically asymptomatic. Mitral Valve Prolapse, mitral stenosis Mitral stenosis Mitral stenosis (MS) is the narrowing of the mitral valve (MV) orifice, leading to obstructed blood flow from the left atrium (LA) to the left ventricle (LV). Mitral stenosis is most commonly due to rheumatic heart disease. Mitral stenosis leads to impaired LV diastolic filling, increased LA pressure, and LA dilation. Mitral Stenosis (MS), aortic stenosis (AS), tricuspid regurgitation Tricuspid regurgitation Tricuspid regurgitation (TR) is a valvular defect that allows backflow of blood from the right ventricle to the right atrium during systole. Tricuspid regurgitation can develop through a number of cardiac conditions that cause dilation of the right ventricle and tricuspid annulus. A blowing holosystolic murmur is best heard at the left lower sternal border. Tricuspid Regurgitation, hypertrophic obstructive cardiomyopathy Cardiomyopathy Cardiomyopathy refers to a group of myocardial diseases associated with structural changes of the heart muscles (myocardium) and impaired systolic and/or diastolic function in the absence of other heart disorders (coronary artery disease, hypertension, valvular disease, and congenital heart disease). Overview of Cardiomyopathies (HOCM), atrial septal defect Atrial Septal Defect Atrial septal defects (ASDs) are benign acyanotic congenital heart defects characterized by an opening in the interatrial septum that causes blood to flow from the left atrium (LA) to the right atrium (RA) (left-to-right shunt). Atrial Septal Defect (ASD), ventricular septal defect (VSD), and patent ductus arteriosus Patent ductus arteriosus The ductus arteriosus (DA) allows blood to bypass pulmonary circulation. After birth, the DA remains open for up to 72 hours and then constricts and involutes, becoming the ligamentum arteriosum. Failure of this process to occur results in patent ductus arteriosus (PDA), a condition that causes up to 10% of congenital heart defects. Patent Ductus Arteriosus (PDA) ( PDA PDA The ductus arteriosus (DA) allows blood to bypass pulmonary circulation. After birth, the DA remains open for up to 72 hours and then constricts and involutes, becoming the ligamentum arteriosum. Failure of this process to occur results in patent ductus arteriosus (PDA), a condition that causes up to 10% of congenital heart defects. Patent Ductus Arteriosus (PDA))

Image by Lecturio.

Audio:

This audio clip is an example of severe aortic stenosis. This is a harsh, crescendo-decrescendo murmur occurring between S1 and S2. Due to the severity of the aortic stenosis, the S2 heart sound is inaudible.

Heart sound by The Regents of the University of Michigan. License: CC BY-SA 3.0

Diagnosis

Transthoracic and Doppler echocardiography

  • Diagnostic imaging of choice
  • Details provided:
    • Structure and function of the valve
    • Valvular findings: decreased aortic valve opening, valvular calcification, bicuspid valve
    • Other findings: LV hypertrophy, aortic wall abnormalities, systolic and diastolic function 
    • Systolic dysfunction or LV ejection fraction (EF) < 50%: important in determining AS management
  • Parameters of stenosis (from Doppler echocardiography):
    • Transvalvular gradient (in mm Hg)
    • Flow velocity with decreased valvular area 
    • Aortic valve area (in cm²):
      • Severe AS: valve area < 1 cm2
      • Moderate AS: valve area 1–1.5 cm2
      • Mild AS: valve area 1.5–2 cm2
  • Additional information provided:
    • Other coexisting valvular disease
    • Hypertrophic cardiomyopathy Hypertrophic Cardiomyopathy Hypertrophic cardiomyopathy (HCM) is the most commonly inherited cardiomyopathy, which is characterized by an asymmetric increase in thickness (hypertrophy) of the left ventricular wall, diastolic dysfunction, and often left ventricular outflow tract obstruction. Hypertrophic Cardiomyopathy
    • Ascending aortic aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms associated with bicuspid valves
    • Coarctation of aorta

Other tests

  • ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG):
    • Results vary and depend on associated structural abnormalities and arrhythmias.
    • May demonstrate left ventricular hypertrophy, left atrial enlargement, and left axis deviation
  • Chest X-ray:
    • On lateral views, aortic valve calcification can be seen.
    • Pulmonary congestion from LV failure can be visualized.
  • Exercise stress testing or exercise tolerance test (ETT):
    • Contraindicated in symptomatic severe AS 
    • Performed in select cases (e.g., unclear level of physical activity, low-gradient AS)
  • Cardiac catheterization and coronary arteriography:
    • Provides information on the pressure gradient between the left ventricle and aorta, and overall hemodynamic assessment when other tests are inconclusive
    • Evaluation of coronary artery disease: an important consideration prior to valvular surgery
  • Multidetector computed tomography (MDCT):
    • Helps in evaluation of low-gradient AS
    • Quantification of aortic valve calcification correlates with severity of stenosis.

Management

General principles

  • Aortic valve replacement (AVR): mainstay of treatment of symptomatic AS
  • To determine candidates for AVR, the following details are obtained:
    • Symptom status
    • Severity of AS: 
      • Severe AS: aortic jet velocity ≥ 4 m/sec, mean transvalvular gradient of ≥ 40 mm Hg
      • Severe AS: typically with < 1 cm² area (but is not required)
    • LV systolic function: LVEF < 50% = systolic dysfunction
  • Indications for AVR:
    • Asymptomatic severe AS:
      • Abnormal ETT (decreased exercise tolerance)
      • With LVEF < 50%
      • Undergoing other cardiac surgery Cardiac surgery Cardiac surgery is the surgical management of cardiac abnormalities and of the great vessels of the thorax. In general terms, surgical intervention of the heart is performed to directly restore adequate pump function, correct inherent structural issues, and reestablish proper blood supply via the coronary circulation. Cardiac Surgery
      • With low surgical risk
      • Rapid disease progression and low surgical risk
    • Symptomatic severe AS
  • For less severe or moderate AS, performing AVR depends on multiple factors:
    • Symptoms
    • Aortic valve area < 1 cm²
    • LVEF 
    • ETT, dobutamine stress echocardiography
    • If undergoing other cardiac surgery Cardiac surgery Cardiac surgery is the surgical management of cardiac abnormalities and of the great vessels of the thorax. In general terms, surgical intervention of the heart is performed to directly restore adequate pump function, correct inherent structural issues, and reestablish proper blood supply via the coronary circulation. Cardiac Surgery

Surgical management

  • For patients with life expectancy > 1 year and if surgery is likely to improve quality of life
  • Transcatheter aortic valve implantation Implantation Endometrial implantation of embryo, mammalian at the blastocyst stage. Fertilization and First Week (TAVI):
    • In patients with intermediate-high surgical risk
    • In patients with low surgical risk meeting feasibility for TAVI
  • Surgical aortic valve replacement (SAVR):
    • In patients with low or intermediate risk and TAVI is not feasible
    • Presence of another indication for cardiac surgery Cardiac surgery Cardiac surgery is the surgical management of cardiac abnormalities and of the great vessels of the thorax. In general terms, surgical intervention of the heart is performed to directly restore adequate pump function, correct inherent structural issues, and reestablish proper blood supply via the coronary circulation. Cardiac Surgery
  • Percutaneous aortic balloon valvuloplasty (PABV):
    • Not a substitute for valve replacement
    • Has high rate of re-stenosis
    • Consider as a bridge to TAVI or SAVR in severe symptomatic AS
    • Palliation for patients who are not good candidates for AVR
    • Has a role for young and adolescent patients

General recommendations for non-surgical management

  • Periodic monitoring: 
    • TTE every 612 months in asymptomatic severe AS
    • TTE every 1–2 years for moderate AS and every 3–5 years for mild AS 
  • Activity:
    • Avoid strenuous physical activity and competitive sports in severe AS.
    • Avoid dehydration Dehydration Volume status is a balance between water and solutes, the majority of which is Na. Volume depletion refers to a loss of both water and Na, whereas dehydration refers only to a loss of water. Dehydration is primarily caused by decreased water intake and presents with increased thirst and can progress to altered mental status and low blood pressure if severe. Volume Depletion and Dehydration (to protect against CO reduction).
  • Medications:
    • Endocarditis Endocarditis Endocarditis is an inflammatory disease involving the inner lining (endometrium) of the heart, most commonly affecting the cardiac valves. Both infectious and noninfectious etiologies lead to vegetations on the valve leaflets. Patients may present with nonspecific symptoms such as fever and fatigue. Endocarditis prophylaxis: with history of infective endocarditis
    • General guidelines: Start with low dose and slowly titrate.
    • Angiotensin-converting enzyme (ACE) inhibitors: may improve LV fibrosis in addition to blood pressure control
    • Beta blockers:
      • Reduce contractility 
      • Continue with coexisting coronary artery disease or atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation
      • For hypertension, consider a low dose but generally avoid with symptomatic AS and heart failure.
    • Diuretics: 
      • Excessive decrease in preload should be avoided.
      • Use with caution if the patient has symptomatic AS (because it reduces ventricular volume).

Prognosis

  • If untreated with surgery, 50% of patients die within 3 years of symptom onset (angina, syncope Syncope Syncope is a short-term loss of consciousness and loss of postural stability followed by spontaneous return of consciousness to the previous neurologic baseline without the need for resuscitation. The condition is caused by transient interruption of cerebral blood flow that may be benign or related to a underlying life-threatening condition. Syncope, or heart failure). 
  • Surgical mortality rate for valve replacement including the elderly is 2%5%.

Differential Diagnosis

  • Hypertrophic cardiomyopathy Hypertrophic Cardiomyopathy Hypertrophic cardiomyopathy (HCM) is the most commonly inherited cardiomyopathy, which is characterized by an asymmetric increase in thickness (hypertrophy) of the left ventricular wall, diastolic dysfunction, and often left ventricular outflow tract obstruction. Hypertrophic Cardiomyopathy: a cardiac condition characterized by a thickened left ventricular wall leading to left ventricular outflow obstruction and diastolic dysfunction. Patients present with exertional dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, syncope Syncope Syncope is a short-term loss of consciousness and loss of postural stability followed by spontaneous return of consciousness to the previous neurologic baseline without the need for resuscitation. The condition is caused by transient interruption of cerebral blood flow that may be benign or related to a underlying life-threatening condition. Syncope, and, in extreme cases, sudden cardiac death. The systolic murmur increases with the Valsalva maneuver and standing. Diagnosis is by echocardiography. Management includes negative inotropic agents with surgical options to reduce the LV outflow obstruction. An implantable defibrillator is placed for those at risk for sudden death.
  • Myocardial infarction Myocardial infarction MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction: an acute blockage of the coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries supplying the heart, which can predispose to structural valvular incompetence. This condition commonly presents with chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain and is diagnosed with ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG) and cardiac enzyme tests.
  • Aortic regurgitation: characterized by the backflow of blood from the aorta to the left ventricle, commonly caused by rheumatic heart disease, and congenital and degenerative valvular disorders. Examination shows an early diastolic high-pitched decrescendo murmur, heard best in the left sternal border. Diagnosis is by echocardiography. The acute form is a medical emergency requiring immediate surgery.
  • Congestive heart failure Congestive heart failure Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure ( CHF CHF Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure) with systolic dysfunction: a chronic, progressive condition characterized by left ventricular dysfunction from impaired myocyte contractility. This leads to subsequent volume overload. Risk factors include hypertension, coronary artery disease, and diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus. Congestive heart failure Congestive heart failure Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure can develop with or without valvular abnormalities.

References

  1. Ahmed, S., & Bernath, G.A. (2017). Valvular heart diseases. Elmoselhi, A. (Ed.), Cardiology: An Integrated Approach. McGraw-Hill.
  2. Bashore, T.M., & Granger, C.B., & Jackson K.P., & Patel M.R. (2021). Aortic stenosis. Papadakis M.A., & McPhee S.J., & Rabow M.W.(Eds.), Current Medical Diagnosis & Treatment 2021. McGraw-Hill.
  3. Gaasch, W., Otto, C., & Yeon, S. (2020) Natural history, epidemiology, and prognosis of aortic stenosis. UptoDate. Retrieved 31 Oct 2020, from https://www.uptodate.com/contents/natural-history-epidemiology-and-prognosis-of-aortic-stenosis
  4. Grimard, B., Safford, R., & Burns, E. (2016) Aortic stenosis: Diagnosis and Treatment. Am Fam Physician. 2016 Mar 1;93(5):371-378.
  5. Mitchell, R., & Halushka, M. (2020) Blood vessels. In Kumar, V., Abbas, A., Aster, J. & Robbins, S. Robbins and Cotran Pathologic Basis of Disease (10th Ed., pp. 557-567). Elsevier, Inc.
  6. O’Gara, P.T., & Loscalzo, J. (2018). Aortic valve disease. Jameson J, & Fauci A.S., & Kasper D.L., & Hauser S.L., & Longo D.L., & Loscalzo J(Eds.), Harrison’s Principles of Internal Medicine, 20e. McGraw-Hill.
  7. Otto, C., Cooper, S., Gaasch, W., & Yeon, S. (2019) Medical management of symptomatic aortic stenosis. UpToDate. Retrieved 1 Nov 2020, from https://www.uptodate.com/contents/medical-management-of-symptomatic-aortic-stenosis
  8. Otto, C., Gaasch, W., & Yeon, S. (2019) Medical management of symptomatic aortic stenosis. UpToDate. Retrieved 1 Nov 2020, from https://www.uptodate.com/contents/medical-management-of-asymptomatic-aortic-stenosis-in-adults
  9. Ren, X., & O-Brien, T. (2019) Aortic stenosis, Medscape. Retrieved 31 Oct 2020, from https://emedicine.medscape.com/article/150638-overview#a5

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