Case Presentation:
In our Morning Report at WCH, we discussed a case of a patient presenting with exertional shortness of breath of three months duration. Clinical assessment and investigations were compatible with a diagnosis of symptomatic aortic stenosis.
Learning Points:
1) Utility of clinical exam findings for aortic stenosis
2) Important aspects on an echocardiogram report for aortic stenosis
3) Indications for surgical intervention in aortic stenosis
Utility of clinical exam findings:
Features that can help rule in aortic stenosis (aka: high specificity):
- Pulsus parvus et tardus
- Decreased S2
- Brachioradial delay
- Apical carotid delay
- Mid-late peaking murmur
Features that can help rule out aortic stenosis (aka: high sensitivity)
- Absence of systolic murmur
- Lack of radiation to clavicle
What to look for on an echocardiogram report:
Looking for features compatible with severe aortic stenosis
| Parameter | Threshold Value |
| Mean Pressure Gradient | >40 mm Hg |
| Vmax (maximum aortic velocity) | >4 m/s |
| Aortic valve area | <1.0 cm2 |
| LV function | <50% |
Surgical Indications:
- Symptomatic aortic stenosis
- Asymptomatic aortic stenosis with impaired LV function (<50%)
- Asymptomatic but severe aortic stenosis (Vmax>5 m/s or Mean gradient>60 mm Hg)
- Asymptomatic but reduced exercise tolerance or blood pressure drop with exercise
- Undergoing other cardiac surgery with severe AoS (Class I recommendation) or moderate AoS (Class IIa recommendation)
References:
- Etchells, E; Bell, C; Robb,K. Does this patient have an abnormal systolic murmur? JAMA 1997; 277: 564-571.
- Etchells, E; Glenns, V; Shadowitz, S; Bell, C; Siu, S. A bedside clinical prediction rule for detecting moderate or severe aortic stenosis. JGIM 1998; 13:699-704.
- 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary. Circulation. 2014;129:2440-2492