Diagnosis
Symptomatic vs. Asymptomatic patients.
H&P
Presentation of symptomatic patients: mild shortness of breath, lightheadedness with exertion…
Treatment
-Treatment for symptomatic aortic stenosis is prompt aortic valve replacement.
-Treatment for asymptomatic patients with mild aortic stenosis is to repeat echocardiography every 3–5 years.
“Symptomatic patients with severe aortic stenosis have 2-year mortality rates of more than 50%. After valve replacement the 10-year survival rate is almost identical to that of patients without aortic stenosis. Watchful waiting with monitoring for symptoms and periodic echocardiograms is indicated for asymptomatic patients with moderate to severe aortic stenosis who have a normal ejection fraction. There is no medical treatment that delays the progression of aortic valve disease or improves survival. Measures to reduce cardiovascular risk, including treatment of hypertension, are indicated. Rate-slowing calcium channel blockers and -blockers that depress left ventricular function should be avoided if possible. ACE inhibitors may improve symptoms in patients with aortic stenosis who are not surgical candidates.” ABFM 2017 critique.
Exertional dyspnea that develops in a patient with aortic stenosis is very concerning.
“When symptoms begin to appear in a patient with aortic stenosis the prognosis worsens. It is therefore important to be aware of systolic murmurs in older patients presenting with exertional dyspnea, chest pain,or dizziness. This can be the first presentation of a downward spiral and the need for rapid valve replacement.” ABFM
Asymptomatic aortic stenosis.
“Although aortic stenosis can result in adverse cardiac events, most of these events occur in patients who are symptomatic. Thus, the American Heart Association and the American College of Cardiology recommend that asymptomatic patients with mild aortic stenosis undergo repeat echocardiography every 3–5 years. Further workup or treatment is not indicated for patients who have mild AS and are asymptomatic. Exercise treadmill testing may be indicated in patients with severe AS based on echocardiography even if they are asymptomatic.
Right and left heart catheterization can be used in an attempt to resolve discrepancies between symptoms and echocardiographic findings. Because this patient is asymptomatic and her echocardiogram shows only mild AS, left and/or right heart catheterization is not indicated. An ACE inhibitor would be indicated in patients who have a reduced ejection fraction.” ABFM
Reference
N Engl J Med 2014;371(8):744-756.
Grimard BH, Safford RE, Burns EL: Aortic stenosis: Diagnosis and treatment. Am Fam Physician 2016;93(5):371-378