Aortic stenosis

Supervisor: dr. Abdul

Hakim Alkatiri, Sp.JP,
FIHA
By: Ruzanna binti
Hassim

PATIENTS IDENTIty
NAME

Mr. J

GENDER

Male

Age

57 y.o

Address

Jl. Komp Dosen Unhas

No Rekam Medik

269246

Tanggal Pemeriksaan

20 April 2015

History taking
Chief complaint: shortness of breath
Shortness of breath was felt around 10 hours
before being admitted to the hospital and it
happened suddenly. Shortness of breath was
felt while doing some common activities such
as walking. The patient also experienced
intermittent chest pain which was felt around 1
year ago and was not accompanied by cold
sweating. There was a history of hypertension
and smoking 3-4 cigarettes per day but has
ceased around 5 years back. There was no
history of breathlessness during recumbent
position and shortness of breath that awakens
the patient while sleeping. Patient experienced
neither sudden blackout, nausea nor vomiting.

 General Status

Moderate illness/normal / Compos Mentis

Weight: 55kg
Height : 160 cm
BMI
: 21.48 kg/m2

Vital Status

Blood pressure
Heart rate
Respiratory rate
Temperature

: 110/70 mmHg
:90 x/min
: 33 x/min
: 36,5 oC

Laboratory results

RESULTS

NORMAL RANGE

UNIT

WBC

7.4

4.00 10.0

[103/uL]

RBC

4.09

4.00 6.00

[106/uL]

HGB

12.6

12.0 16.0

[g/dL]

HCT

35.5

37.0 48.0

[%]

PLT

289

150 400

[103/uL]

Creatinine

3.40

<1,3

mg/dl

Ureum

66

0-50

Mg/dl

SGOT

242

<41

u/L

SGPT

79

<38

u/L

aPTT

46. 1

22,1-28,1

Detik

INR

1.29

Detik

CK

732

M<190 F<167

U/L

CK-MB

71.6

<25

U/L

TROPONIN T

0.60

<0.05

ng/ml

Fasting blood glucose

147

110

mg/dl

HEMATOLOGY

Diagnostic examinations

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Sinus rhythm
Heart rate
Axis
P Wave
PR interval
QRS Complex

ST segment

: 100bpm
: Normal axis
: 0.08 s
: 0.20 s
: Duration : 0.08 s
: ST elevation at V1, V2

Conclusion :
Sinus rhythm, HR 100 bpm, normal axis, ST
elevation at V1, V2

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Sinus rhythm
Heart rate
: 93bpm
Axis
: Normal axis
P Wave : 0.08 s
PR interval
: 0.20 s
QRS Complex : Duration : 0.04 s
Configuration : Q pathologic at V1,
V2,
V3, V4, V5
T wave
:inverted at V1, V2, V3, V4,
V5,V6

Conclusion :
Sinus rhythm, HR 93 bpm, normal axis, left
ventricular hypertrophy ( 23mm+26mm=49mm)

Chest X-ray
Cardiomegaly with signs of lung
congestion
Dilatation of aorta

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Electrocardiography

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Electrocardiography

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Electrocardiography

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Electrocardiography

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Electrocardiography

Systolic and diastolic dysfunction

Left ventricular ejection fraction 42%
Left ventricular hypertrophy
Aortic stenosis severe
Hypo kinetic anteroseptal

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Aspilets 80mg/24 hours/oral

Clopidogrel 75 mg/24 hours/oral
Corsel 1tab/12 hours/oral
Atorvastatin 20 mg/24 hours/oral
Maintate 1.25 mg/24 hours/oral
Furosemide 40mg/12hours/oral
Laxadine syrup 15ml/24 hours/oral
Alprazolam 0.5mg/24 hours /oral
Lovenox 0,6cc/24hours/subcutaneous

Aortic stenosis

INTRODUCTION

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Aortic Stenosis

Etiology
Physical Examination
Assessing Severity
Natural History
Prognosis
Timing of Surgery

Aortic Stenosis - Aetiology

Congenital 1st-3rd decade

Valve degeneration and calcification
Rheumatic - 4th decade
Bicuspid valve; 1%, males>females, 5-6th decades
Tricuspid valve - 7-8th decades, 1-2% incidence

Aortic Stenosis - Etiology

Young patient
think congenital
Bicuspid
2% population
3:1
male:female
distribution
Co-existing
coarctation 6%
of patients

Rarely
Unicuspid valve
Sub-aortic stenosis
Discrete
Diffuse (Tunnel)

Middle aged
patient(4&5th decades)
think bicuspid or
rheumatic disease
Old patient think
degenerative (6,7,8th
decades)

Aortic Stenosis: Etiology

Congenital bicuspid valve is the most
common abnormality
Rheumatic heart disease and
degeneration with calcification are found
as well

Normal

Bicuspid Ao V

Normal geriatric
calcific valve

Bicuspid Aortic Valve

Aortic Stenosis:
Asymptomatic
Common in asymptomatic adults
Characterized by
Grade I II @ LSB
Systolic ejection pattern

S1
S2
Normal intensity & splitting of second sound (S2)
No other abnormal sounds or murmurs
No evidence of LVH

Aortic Stenosis: Symptoms

Cardinal Symptoms
Chest pain (angina)
Reduced coronary flow reserve
Increased demand-high afterload

Syncope/Dizziness (exertional pre-syncope)

Fixed cardiac output
Vasodepressor response

Dyspnea on exertion & rest

Impaired exercise tolerance

Other signs of LV failure

Diastolic & systolic dysfunction

Common Murmurs and

Timing (click on murmur to
play)
Systolic Murmurs
Aortic stenosis
Mitral insufficiency
Mitral valve prolapse
Tricuspid insufficiency
Diastolic Murmurs
Aortic insufficiency
Mitral stenosis
S1

S2

S1

Aortic Stenosis: Physical

Findings

S1

S2

Mild-Moderate

S1

S2
Severe

Aortic Stenosis: Physical

Findings
Intensity DOES NOT predict severity
Presence of thrill DOES NOT predict
severity
Diamond shaped, harsh, systolic
crescendo-decrescendo
Decreased, delay & prolongation of pulse
amplitude
Paradoxical S2
S4 (with left ventricular hypertrophy)
S3 (with left ventricular failure)

Severity of Stenosis

Normal aortic valve area 2.5-3.5 cm2

Mild stenosis 1.5-2.5 cm2
Moderate stenosis 1.0-1.5 cm2
Severe stenosis < 1.0 cm2
Onset of symptoms
~0.9 cm2 with CAD
~0.7 cm2 without CAD

Echocardiogram
Etiology
Valve gradient and
area
LVH
Systolic LV function
Diastolic LV function
LA size
Concomitant regional
wall motion
abnormalities
Coarctation associated
with bicuspid AV

Aortic Stenosis: Prognosis

Symptom/Sign
Angina

Live
expectancy
5 years

Syncope

2-3 years

Congestive Heart Failure

1-2 years

Therapy: Valve replacement for severe aortic stenosis

Operative mortality (elderly) ~ 4-24%/Morbidity ~ 3-11%
Event rate in asymptomatic severe AS ~ 1%/year

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Natural History of Aortic

Stenosis
Heart failure reduces
life expectancy to
less than 2 years
Angina and syncope
reduce life
expectancy between
2 and 5 years
Rate of progression
@ 0.1 cm2/year

THANK YOU

11/18/16