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Aortic stenosis

Definition
  • Aortic Stenosis (AS): A valvular heart condition characterised by the narrowing of the aortic valve opening, restricting blood flow from the left ventricle to the aorta.
Etiology
  • Degenerative: Age-related calcific changes (most common in elderly).
  • Congenital: Bicuspid aortic valve, which becomes calcified and stenotic in adulthood.
  • Rheumatic: Rheumatic heart disease following streptococcal pharyngitis.
Pathophysiology
  • Progressive valve narrowing ā†’ increased left ventricular (LV) afterload ā†’ compensatory LV hypertrophy.
  • With time, this may lead to diastolic dysfunction, heart failure and increased myocardial oxygen demand.
Clinical Features
  • Classic Triad: Dyspnoea, angina, and syncope on exertion.
  • Physical Examination: Slow-rising pulse, narrow pulse pressure, ejection systolic murmur heard best at the right upper sternal border with radiation to the carotids.
Investigations
  • ECG: Signs of LV hypertrophy.
  • Chest X-ray: Cardiomegaly, calcified aortic valve.
  • Echocardiography: Gold standard; measures valve area, gradient, and assesses LV function.
Management
  • Conservative: Lifestyle modifications, regular monitoring, endocarditis prophylaxis if needed.
  • Medical: Limited role, but can use diuretics for symptoms of heart failure. Antihypertensives cautiously.
  • Surgical: Aortic valve replacement (mechanical or bioprosthetic) is the definitive treatment. Indicated in symptomatic patients or those with LV dysfunction. Balloon valvuloplasty may be considered in selected cases.
Complications
  • Left ventricular failure.
  • Arrhythmias.
  • Sudden cardiac death.
  • Endocarditis (rare).
Key Points
  • AS is the most common valvular heart disease in the developed world.
  • The classic triad of symptoms often suggests severe stenosis.
  • Echocardiography is pivotal in the diagnosis and assessment of AS.

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