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Aortic valve stenosis
Most patients with calcific aortic stenosis report knowing of a
cardiac murmur for many years. Common symptoms of aortic
stenosis include: coughing at night; fainting, especially with
physical activity; fatigue; shortness of breath that worsens at
night or with exertion; angina; and, visual impairments. Some
patients may also experience exertional syncope, probably
reflecting the inability to increase cardiac output and maintain
blood pressure in response to vasodilation. Vasodepressor
syncope, however, may be an operative mechanism in a portion of
these syncopal episodes.
On physical examination, the harsh systolic diamond shaped
(crescendo-decrescendo) murmur of aortic stenosis, loudest at the base of the heart and radiating to the
carotids, is often, but not always, prominent. Low output
states, obesity, or chronic lung disease may mask the findings.
The murmur may radiate toward the cardiac apex, in which case
the harsh component is lost; this finding may be mistaken for a
second murmur. Other hallmarks of significant aortic valve
stenosis include a single (pulmonic) component of the second
heart sound and a sustained left ventricular apical impulse with
a fourth heart sound. The slowly rising, low volume carotid
arterial pulses of severe aortic stenosis may be noted in
younger patients, but changes in arterial compliance often mask
these findings in the elderly.
Patients with typical findings of aortic stenosis should have a
detailed history-taking session with inquiry into habitual
activity levels and any changes in exercise tolerance. The onset
of any of the classic symptoms of left ventricular outflow
obstruction, namely angina, syncope, or heart failure, in a
patient with valvular aortic stenosis indicates advanced valve
disease and should be carefully and promptly evaluated. The
severity of symptoms is not always related to the severity of
the disease. In fact, people sometimes die suddenly from aortic
stenosis without having had symptoms. Symptoms usually occur
when the aortic valve area narrows to less than 1 square
centimeter. Critical aortic stenosis is present when the valve
area is less than 0.7 square centimeters.
The electrocardiogram often shows changes of left ventricular
hypertrophy. In rare instances, electrical conduction
abnormality can also been seen.
The chest X-ray is seldom helpful, although occasionally heavy
calcification of the valve or post-stenotic ascending aortic
dilation may be seen.
With its widespread availability, two-dimensional and Doppler
echocardiography has become the study of choice in the
evaluation of patients with suspected valvular disease.
Echocardiography allows assessment of the anatomy of the valve
as well as chamber size and ventricular function. Doppler
studies permit estimation of pressure gradients, as well as
aortic valve area by employing the continuity equation.
With good quality echocardiography, cardiac catheterization is
usually not required for diagnosis of patients with aortic
stenosis. However, a cardiac catheterization is the gold
standard in evaluating aortic stenosis. A pre-operative coronary
angiography is generally performed in men over 40 years old and
women over 50.
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