Does my patient have significant aortic stenosis?

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Question: Does my patient have significant aortic stenosis?

A 72 year-old woman with a history of CHF presents with several weeks of gradually progressive dyspnea on exertion (DOE). At her baseline, she is able to walk several blocks, but now feels winded. She denies chest pain, palpitations, syncope/near syncope, cough, orthopnea, or PND. She states she is compliant with her medications and diet. She has had a recent functional study that showed minimal ischemia.

Meds

aspirin
digoxin 0.125 qd
lisinopril 20 mg qd
furosemide 20 mg qd
KCl 10 mEq qd

PE

HR 90, regular
PB 134/70

Labs

chem 7:
Na 132
K 5
Cl 94
HCO3 30
BUN 18
Cr 1.3
CBC: notable for Hgb 14 g/dL (Hct 43%)

CV

RRR, normal S1 and S2
No S3 but has S4
2/6 mid-peaking systolic murmur at the LUSB that radiates to the carotids.

PMI is mildly enlarged and sustained

Neck

Carotid pulse is brisk.
JVP flat
Positive abdominojugular reflux

CXR

Xray shows cardiomegaly and mild vascular redistribution

ECG

Unchanged with an incomplete LBBB pattern

Clinical Diagnosis

Worsening of her congestive heart failure (positive AJR, enlarged and sustained PMI, cardiomegaly, and vascular redistribution).

Clinical Questions

Is this patient’s worsening CHF due to significant aortic stenosis?

Please elaborate why you think it may be aortic stenosis according to the patient’s symptoms and how do you assess each symptom.

 

Sample Solution

Question: Does this patient have significant aortic stenosis?

Analysis:

This 75-year-old woman with a history of CHF presents with worsening dyspnea on exertion, suggesting a decline in cardiac function. While her current medications and CHF likely contribute to her symptoms, the presence of a 2/6 systolic ejection murmur radiating to the carotids raises strong suspicion for aortic stenosis (AS).

Here’s how we assess each symptom for potential aortic stenosis:

  • Dyspnea on Exertion: A hallmark symptom of AS. The left ventricle must exert more force to eject blood through the narrowed aortic valve, leading to increased myocardial workload and reduced cardiac output. This can manifest as shortness of breath, especially with exertion.
  • Fatigue: A common symptom of AS due to decreased cardiac output and reduced oxygen delivery to tissues.
  • Chest Pain (Absent in this case): While not present in this patient, chest pain (angina) is a common symptom of AS, particularly with exertion.
  • Syncope/Near Syncope (Absent in this case): These can occur in severe AS due to decreased cerebral blood flow.
  • Physical Exam Findings:
    • Systolic murmur radiating to carotids: This is a highly suggestive finding for AS. The murmur arises from turbulent blood flow across the stenotic aortic valve.
    • S4 heart sound: An S4 heart sound can be heard in patients with AS due to atrial contraction against a stiff left ventricle.
    • Diminished carotid pulses: In severe AS, the carotid pulses may be weak or delayed due to reduced blood flow through the stenotic valve.
    • Cardiomegaly: Left ventricular hypertrophy can occur as the heart works harder to overcome the obstruction.
    • JVP: Elevated JVP can be seen in patients with right ventricular failure secondary to severe AS.

Other Considerations:

  • Age: The patient’s age (75 years) increases the likelihood of age-related valve degeneration, a common cause of AS.
  • Medications: While lisinopril can cause cough, it can also improve symptoms of heart failure.

Further Evaluation:

  • Echocardiogram: This is the most crucial investigation. Echocardiography can assess the severity of aortic stenosis by measuring the aortic valve area, peak and mean gradients, and left ventricular function.
  • ECG: While the ECG may show left ventricular hypertrophy, it may not always reveal the severity of AS.

Conclusion

Based on the patient’s presentation, including the presence of a systolic ejection murmur radiating to the carotids, S4 heart sound, and worsening dyspnea on exertion, significant aortic stenosis is a strong possibility. Further evaluation with echocardiography is essential to confirm the diagnosis and assess the severity of the condition.

Disclaimer: This information is for general knowledge and educational purposes only and does not constitute medical advice.

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