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1、Board Review,Vikram Chhokar MD University of Tennessee Division of Cardiology,Question,An 80-year-old Asian woman awakens at 2 a.m. feeling as if she were being smothered. She is brought to the ED and is found to be in pulmonary edema. She has a history of a heart murmur, discovered 20 years before.
2、 Prior to this episode she says she was in good health, although she has not been physically active due to arthritic discomfort for the past 5 years. On careful questioning she admits to brief episodes of pressure-like sensation in her chest especially when she becomes aggravated.,Question,Physical
3、examination: BP 150/110 mmHg, pulse 120/min, respirations 24/min. Neck veins 10cm. Lungs have rales 3/4 the way up posteriorly bilaterally. Carotids are difficult to feel. PMI is in the 5th intercostal space just outside the midclavicular line and sustained. There is a grade II/VI systolic ejection
4、murmur at the base and a grade II/VI diastolic blowing murmur at the 3rd left intercostal space. There is an S4 and an S3 gallop. There is no hepatomegaly and no pedal edema.,Question,Laboratory : Chest X-ray: slightly enlarged cardiac silhouette, pulmonary vascular redistribution and pulmonary edem
5、a. ECG: QS in V1, a small r in V2, a 25mm R wave in V5 and a 30mm R wave in V6. There is 2mm ST-segment depression in V4-6 . Echo: estimated EF 55%, first troponin 70 yrs old),Bicuspid Aortic Valve,The most common congenital cardiac abnormality is bicuspid aortic valve affecting 1-2% of the U.S. pop
6、ulation. Over time, one-third to one-half of such valves become stenotic, with significant narrowing of the aortic orifice typically developing in the 5th and 6th decades of life.,Aortic Stenosis Key Points,MCC of AS is senile degenerative changes In patients with AS due to rheumatic dz r/o “silent”
7、 mitral stenosis. Bicuspid or rheumatic should be suspected in pt with AS presenting in 5th or 6th decade of life.,Pathophysiology,Increase in afterload Decrease in systemic and coronary flow from obstruction Progressive hypertrophy,Classic symptom triad,Dyspnea Angina Syncope,Classic symptom triad,
8、Once any of these classic symptoms develop, prognosis dramatically worsens. Thus, within 5 years of the development of angina, approximately 50% of patients will die unless aortic valve replacement is performed. For syncope, 50% survival is 3 years For congestive heart failure, 50% survival is only
9、2 years unless the valve is replaced. Angina 5, Syncope 3, and CHF 2.,Characteristic Physical findings,Dampened upstroke of carotid artery Sustained bifid left ventricular impulse Absent A2 Late-peaking systolic ejection murmur A concomitant systolic thrill indicates the presence of AS (mean gradien
10、t 50mm Hg) Of note if you have significant Physical finding and symptoms, you must rule out severe AS.,Aortic Stenosis,Patients with the physical findings of AS should undergo selected laboratory examinations, including an ECG, a chest x-ray, and an echocardiogram. The 2-D echocardiogram is valuable
11、 for confirming the presence of aortic valve disease and determining left ventricular (LV) size and function, degree of hypertrophy, and presence of other associated valve disease.,EKG,Usually shows NSR with LVHNote: If AF is present, concomitant mitral valve disease or thyroid dz must be suspected.
12、,Recommendations for Echocardiography in AS,Class 1 Diagnosis and assessment of severity of AS. Assessment of LV size, function, and/or hemodynamics. Reevaluation of patients with known AS with changing symptoms or signs. Assessment of changes in hemodynamic severity and ventricular compensation in
13、patients with known AS during pregnancy. Reevaluation of asymptomatic patients with severe AS. Class IIa Reevaluation of asymptomatic patients with mild to moderate AS and evidence of LV dysfunction or hypertrophy. Class III Routine reevaluation of asymptomatic adult patients with mild AS having stable physical signs and normal LV size and function.,
