Symptoms of aortic stenosis (AS)

Important symptoms of AS are

1.    Exertional angina

2.    Exertional syncope

3.    Exertional dyspnea

What is the mechanism of dyspnoea in AS.

          Dyspnoea in AS is due to left ventricular dysfunction resulting in elevated pulmonary capillary pressure.

What is the mechanism of angina in AS

          Angina occur due to the imbalance between myocardial oxygen supply and demand.

1.    There is increased myocardial oxygen demand due to left ventricular hypertrophy (LVH).

2.    Decreased blood supply is due to an increase in left ventricular end diastolic pressure which decreases the coronary perfusion gradient.

What is the mechanism of syncope in aortic stenosis

          Syncope is due to reduction  in cerebral blood flow.

Mechanisms are

1.    Systemic vasodilation against a fixed cardiac output

2.    Transient atrioventricular arrhythmia

3.    Transient AV block

4.    Vasodepressor response due to baroreceptor malfunction

How will you correlate the development of symptoms with survival in AS

Symptom	Duration of survival
Angina	5 yrs
Syncope	3 yrs
Dyspnoea	2 yrs
Cardiac failure	1.5yrs

Describe the other presentations of AS

          Other presentations of AS are

-          Cardiac failure (CCF)

-          Infective endocarditis (IEC)

-          Sudden cardiac death - it may be due to complete heart block or atrial tachyarrhythmia

-          Gastrointestinal bleeding

What is the mechanism of CVA in AS

1.    Due to embolism from thrombi in valve

Why gastrointestinal bleeding occur in AS

 Angiodysplasia, particulary in persons with calcific AS. A pure aortic valve disease may remain asymptomatic for 10-15 years.

What are the causes of aortic stenosis

Causes of aortic stenosis vary depending on age of the person.

Causes in young adults

-          Congenital valvular lesion

-          Congenital supravalvular lesion

-          Congenital subvalvular lesion

Middle aged persons

-          Bicuspid aortic valve

-          Rheumatic aortic stenosis

Elderly people causes are

-          Bicuspid aortic valve

-          Rheumatic AS

-          Senile degenerative AS

Other rare causes are

Familial hypercholesterolemia

Ochronosis

The common causes of AS are the following

-          Rheumatic AS

-          Congenital bicuspid aortic valve

-          Aortic sclerosis

-          Functional AS

          Supravalvular AS may be associated with Elfin facies, mental retardation and hypercalcemia. Elfin facies include broad forehead, pointed chin, cupid’s bow like upperlip – upturnal nose, hypertension and low set ears.

Causes of thrill in different areas of pericardium

Definition of thrill

Thrill is defined as a palpable murmur that correlates with zones of maximum intensity of auscultated sounds.Thrill may be felt in mitral area, aortic area, pulmonary area or tricuspid area. The causes vary accordingly. Thrill may be either systolic or diastolic.

Thrill in mitral area

1.      Systolic thrill -the causes are

-             MR

-             VSD

-             ASD (ostium primum)

2.      Diastolic thrill

-             MS (commonest cause)

-             Left atrial myxoma rare cause

Thrill in aortic area

      Thrill in aortic area is commonly systolic

      It is due to a aortic stenosis

Thrill in pulmonary area

      Usually it is systolic

-             Pulmonary stenosis

-             Atrial septal defect

-             High ventricular septal defect

-             Fallot’s tetralogy

-             Patent  ductus arteriosus (continuous thrill)

Tricuspid area thrill

Usually systolic thrill, causes are

1.      Ventricular septal defect

2.      Tricuspid incompetence

3.      ASD (Ostium primum)

4.      Pulmonary stenosis (infundibular type)

What is the significance of apex beat

Apex beat will give idea about enlargement of cardiac chambers and activity of myocardium.

How to localise the apex beat

1.  Ask the patient to lie flat

2.  Stand on the right side of patient

3.  Place your right palm over the pericardium

4.  With the pulp of the finger localise he definite impulse

5.  Locate the thrust by counting the ribs and measure how far it is from midclavicular line.

6.  If the apex beat is not palpated in dorsal decubitus posture. Make the patient sit and lean forward and try.

7.  If not palpated in sitting also look for apical thrust on right side of chest – to rule out dextrocardia.

8.  If then not palpable comment as could not be localised properly.

You should not localise the apex beat in the left lateral position because there is shift of apex beat to the left side for about 1-2cm in the left lateral position.
Where is the position of normal apex beat

    Normal apex beat is in the left 5^th intercostal space half inch medial to midclavicular line.

What are the causes of nonpalpable apex beat

Apex beat may not be palpable due to following reasons.

1.  Apex beat lying behind the rib

2.  Obesity or thick chest wall

3.  Emphysema

4.  Pleural effusion

5.  Pericardial effusion

6.  Constrictive pericarditis

7.  Pneumothroax

8.  Deformity of chest wall – kyphoscoliosis

9.  Pendular breast in females

10. Acute myocardial infarction

11. Heart failure

12. Dextrocardia

What are the different characters of apex beat

1.  Normal apex beat :It is in the left 5^th intercostal  ½ inch medial to left midclavicular line, a brief tap confined to an area of 2- 3 cm diameter. Not much forceful.

2.  Hyperdynamic : Apex beat means forceful and ill sustained impulse occur due to diastolic overload of left ventricle, occur in mitral regurgitation, aortic regurgitation, ventricular septal defect and patent ductus arteriosus. There is no obstruction of blood flow from let ventricle.

3.  Heaving apex beat : Here it is forceful and well sustained occur due to systolic overload of ventricle. Apex beat is well sustained due to obstruction of left ventricular outflow. Examples are aortic stenosis, systemic hypertension, coarctation of aorta, obstructive cardiomyopathy.

4.  Tapping apex : Apex beat is of low amplitude and it is ill sustained occur in mitral stenosis and tachycardia.

5.  Hypokinetic apex beat : Thrust of apex beat is minimal. Occur in myocardial infarction, pericardial effusion, constrictive pericarditis, myxoedema shock.

What do you mean by Palpitation

Palpitation is the abnormal and unpleasant awareness of one’s own heart beat.

The causes of palpitation can be cardiac and non cardiac

Cardiac causes of palpitation are

1. Valvular heart disease

1. Aortic regurgitation
2. Mitral regurgitation
3. Tricuspid regurgitation
4. Mitral stenosis
5. 2. Congenital heart disease

1.  Atrial septal defect
2. Ventricular septal defect
3. Patent ductus arteriosus

3. Paroxysmal atrial tachycardia

4. Atrial fibrillation

5. Ventricular ectopics

6. Brady arrhythmia

Noncardiac causes of palpitation are

1. Hyperkinetic circulatory states such as 
1.Severe anemia.

2.Thyrotoxicosis

3.Arteriovenous shunt

4.Anxiety

5.Pyrexia

2. Drugs can cause palpitation they are

1. Sympathomimetics
2. Vasodilators

3. Non organic causes are
 1.Excessive smoking.
2.Anxiety
3.Cardiac neurosis

4. Others are – Hypoglycemia and pheochromocytoma

Describe the pulse in aortic regurgitation

The pulse in aortic regurgitation is called as Corrigans pulse or collapsing pulse.

1.    It has rapid upstroke.

2.    Rapid down stroke.

3.    ill sustained peak.

it is due to the

1.    Early diastolic reflux of blood into the left ventricle.

2.    There is low systemic vascular resistance.

Bisferien’s pulse may be seen in

1.    Moderate to severe AR.

2.    Moderate AR with mild AS.

What are the factors that affect pulse in AR

 Following factors may affect the pulse volume in AR.

They are

1.    Hypertension.

2.    Hypovolemia.

3.    Left ventricular dysfunction.

4.    Age of the patient.

5.    Associated aortic stenosis .

What are the factors that decrease the pulse volume

1.    Hypovolemia.

2.    Pulmonary artery hypertension.

3.    Left ventricular dysfunction.

4.    Associated valvular lesion – aortic stenosis.

What are the factors which increases the pulse volume in AR

1.    Hypertension.

2.    Elderly people.

3.    Young people

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