History

Fact Explanation
Asymptomatic The patient is asymptomatic until the Aortic Stenosis (AS) is moderately severe. (less than one third of its normal size.)[1]
Angina To over come the partial obstructed aortic valve the less ventricle hypertrophies and this increases the myocardial oxygen demand. So with exertion the hear rate increases and the duration of the diastole reduces. Myocardial perfusion mainly occurs during the diastole. With exertion angina results. patient complains tightening type retro-sternal chest pain wich radiates to the left arm and neck. [1],[2]
Recurrent syncope With the reduced valve surface area the cardiac output diminishes which becomes more significant during exertion. So the patient complains of dizziness and might faint. Once the symptoms of angina, syncope, or heart failure develop, average survival reduces dramatically to less than 2 to 3 years. [1],[3] Syncope at rest may be induced by transient ventricular tachycardia, atrial fibrillation, or atrio-ventricular block. [4]
Features of heart failure. Eg: Paroxysmal nocturnal dyspnea, orthopnea, dyspnea on exertion, and shortness of breath. Once the AS is not treated for a long time heart failure develops. Once symptomatic heart failure has developed the average survival is very poor. [2]
Triad of chest pain, heart failure and syncope. [3] Aortic stenosis may lead to heart failure and/ or exertional angina and syncope.
Palpitations Palpitation is the awareness of ones own heart beat.
History of Rheumatic Fever (RF) This is common in developing countries and occur 5 to 10 years after the RF. By the time the aortic valve is affected the Mitral valve is also affected.
References
  1. ACC/AHA Practice Guidelines. Guidelines for the Management of Patients With Valvular Heart Disease. Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 1998; 98: 1949-1984.
  2. PERERA S1, WIJESINGHE N, LY E, DEVLIN G, PASUPATI S. Outcomes of patients with untreated severe aortic stenosis in real-world practice. N Z Med J. 2011 Nov 4;124(1345):40-8.
  3. VAHANIAN A, ALFIERI, ANDREOTTI F, ANTUNES MJ, BARON-ESQUIVIAS G, BAUMGARTNER H, et al. Guidelines on the management of valvular heart disease. Eur Heart J. Oct 2012, 33,2451-96.
  4. WOLFE RR et al. arrythmias in patients with valvular aortic stenosis, valvular pulmonary stenosis and ventricular septal defects. Results of 24hour ECG monitoring. Circulation, 1993 Feb, 87, 89-101.

Examination

Fact Explanation
Small volume slow rising pulse This is due to the obstructed left ventricular output.
Undisplaced forceful apex beat In order to overcome the AS the left ventricle hypertrophies and this increases the muscle bulk and causes forceful apex. Since there is no volume overload for the ventricles to dilate th eapex is not displaced.
Double impulse of the apex This is a relatively rare finding. Second impulse is due to the forth heart sound (S4) or due to the atrial contraction.
Systolic thrill in the aortic area Due to the turbulent flow across the stenosed aortic valve a thrill is palpable.
Ejection systolic murmur The murmur is crescendo- decrescendo in type. (Diamond shape) Severe the narrowing longer the murmur,but with very severe narrowing the murmur may be inaudible, because the blood flow across the valve is very limited that is is unable to create a turbulent flow and hence the murmur becomes inaudible. This murmur typically radiates to the carotid arteries. Once the aortic valve becomes calcified or become immobile the aortic component (A2) of the second heart sound becomes inaudible, otherwise mobile valves produce an ejection systolic click.
Reversed splitting of the second heart sound. Once the obstruction is very severe the left ventricle takes longer time to eject blood. This delays the closure of the aortic valve.
References

Differential Diagnoses

Fact Explanation
Aortic sclerosis The auscultation finding is similar to AS, but the pulse volume is normal and the murmur does not radiate to the carotids.
Hypertrophic cardiomyopathy Hypertrophy of the septal muscles obstruct the left ventricular outflow. There will be double impulse of the cardiac apex.
Sub valvular AS A congenital condition. The fibrous ridge or the diaphragm is situated immediately below the aortic valve. [1]
Supra valvular AS This is also a congenital condition. A part of the Williams syndrome. (Mental retardation, hypercalcemia and Supra valvular AS) [1]
Myocardial infarction (MI) Angina on exertion should alert about the differential diagnosis of MI.
References
  1. KUMAR Parveen, CLARK Michael, Kumar & Clark’s Clinical Medicine. Seventh Edition. London. 2009. pg765-766

Investigations - for Diagnosis

Fact Explanation
Chest X Ray (CXR) Relatively small heart with a prominent dilated ascending aorta. This is due to the post-stenotic dilatation. A calcified aortic valve will also be visible. Once heart failure develops CXR will show the features of heart failure. Eg: Cardiomegaly, Kerly B lines, Pleural effusions.
Electrocardiogram (ECG) In severe disease left ventricular hypertrophy will be seen and left ventricular strain pattern occurs due to pressure overload (ST segment depression and T wave inversion of left ventricular leads: Lead I, aVL, V5 and V6).
2D Echo cardiogram Thickened, calcified and immobile aortic valve cusps will be seen. Left ventricular wall hypertrophy can be demonstrated. The pressure gradient across the valve and the valve surface area can be determined.
Cardiac catheterisation This is rarely necessary since 2D echo can give the same details which is non invasive.
References

Investigations - Fitness for Management

Fact Explanation
Full blood count Low hemoglobin levels will aggravate heart failure and angina on exertion. So it should be corrected.
Exercise stress testing Exercise stress testing is an important and safe investigation in asymptomatic severe AS. [1]
Trans esophageal Echo cardiogram This will help to rule out or to diagnose infective endocarditis, so it can be treated prior to the surgery.
References
  1. THIBAULT G, DESANCTIS RM, BUCKLEY MJ, Aortic stenosis in the practice of cardiology. 2nd edition. 1989. Little, Brown and Co, Boston. Toronto

Investigations - Followup

Fact Explanation
2D Echo cardiogram This is done in the post operative period to ensure the surgical correction. Patients who have mild AS yearly physical examination and echo in every 5 years should be done. Moderate AS patients should undergo an echo once in two years. Severe AS should be examined twice yearly and whenever they have symptoms. Symptomatic patients should be followed up yearly. [1]
References
  1. ACC/AHA Practice Guidelines. Guidelines for the Management of Patients With Valvular Heart Disease. Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 1998; 98: 1949-1984

Investigations - Screening/Staging

Fact Explanation
2D Echo cardiogram People with increased risk to develop AS (Congenital bicuspid aortic valve, History of rheumatic carditis) can be screened. The valve surface area can be detected and the severity of the lesion can be categorized.
References

Management - General Measures

Fact Explanation
Treat anemia Anemia can worsen the heart failure, and may precipitate angina.
Treat Infective Endocarditis (IE) If IE is present antibiotic treatment should be initiated.
Antibiotic prophylaxis against IE Routine use of prophylactic antibiotics is not recommended. However it is indicated when the risk of IE is high. Eg: Presence of prosthetic heart valves, history of IE, congenital cyanotic heart diseases which are not repaired. [1] Once a prosthetic heart valve is being placed the patient should be on life long warfarin and antibiotic prophylaxis against IE when there is a significant risk of septicemia.
Management of heart failure If heart failure is present it should be managed concurrently with aortic stenosis.
References
  1. HABIB U, Rehman. Antibiotic prophylaxis is different in guidelines, BMJ Mar 22, 2008; 336 (7645): 630

Management - Specific Treatments

Fact Explanation
Aortic valve replacement Asymptomatic patients are best managed in this way and has a good outcome. [1] This shows a symptomatic improvement and an increase in survival in patients with angina, dyspnea, or syncope. [2] There is no age limit for aortic valve replacement in patients with aortic stenosis provided there are no other comorbid conditions. [3]
Per cutaneous balloon aortic valvotomy Balloon valvotomy can be done as a temporary method of relieving the symptoms in symptomatic patients who are not initially candidates for AVR. Once the symptoms are controlled definitive surgery can be performed. [2]
References
  1. CHEITLIN MD, ALPERT JS, ARMSTRONG WF, et al. ACC/AHA guidelines for the clinical application of echocardiography: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Clinical Application of Echocardiography), developed in collaboration with the American Society of Echocardiography. Circulation. 1997;95:1686–1744.
  2. ACC/AHA Practice Guidelines. Guidelines for the Management of Patients With Valvular Heart Disease. Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 1998; 98: 1949-1984
  3. WONG J, SALEM DN, PAUKER SG. You’re never too old. N Engl J Med. 1993; 328: 971–975.