Aortic Stenosis

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Aortic Stenosis Heart Failure

• By Emily Oakford
• GP ST2

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Case presentation

• 82 year old man
• Presented via A E after collapse on street
• Occurred on exertion
• Pt does not recall collapsing
• After short time felt back to normal

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Past Medical History

• Known heart murmur
• Discovered 1 year prior to this presentation
• Had similar collapse then thought due to
  dehydration
• Had echo as opt with GP follow up
• Told had a slightly leaky heart valve, nothing
  to worry about
• No cardiology review
• HT
• Arthritis

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• DH
• Felodipine 10mg OD
• Bendrofluazide 2.5mg OD
• NKDA
• SH
• Lives alone in bungalow
• Non smoker
• Alcohol nil
• Retired traffic engineer

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Clinical Examination

• CVS
• Slow rising pulse, BP 132/58, P 77
• JVP not raised
• Loud ejection systolic murmur
• Absent 2nd heart sound
• No peripheral oedema
• Resp
• Chest clear
• Abdo
• Soft, non-tender
• Neuro
• No focal neurological deficit

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Investigations

• Urine NAD
• Bloods
• Hb 11.4, Wbc 9.4, Plt 263
• Na 137, K 4.2, Cr 110
• CRP 3
• No postural BP drop

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ECG
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CXR
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Investigations

• Old echo result from Feb 2007 obtained
• Aortic valve heavily calcified with poor
  excursion
• Aortic valve gradient 73 mmHg
• Area 0.80
• Good LV function
• Mild Tricuspid Regurgitation

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Management

• Impression
• Syncope due to aortic stenosis
• Echo on admission
• Severe Aortic Stenosis
• Gradient 67 mmHg, area 0.55, velocity max 4m/s
• Mild TR
• Mild/Mod MR
• Good LV function
• Had inpatient angiogram
• Transferred to St. Thomas Hospital for Aortic
  Valve Replacement

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• Aortic Stenosis

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Aortic Stenosis
Resistance to blood flow
Aortic Stenosis
Exercise
Ventricle working harder
Unable to get enough bloodsupply
Thickened ventricular wall
Ventricle requires more blood supply
Heart failure
Symptoms
Weaken heart muscle
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During Exercise
Exercise
Vasodilatation
Lowers blood pressure
Raise blood pressure
Increase Cardiac output
Faint
Aortic Stenosis
Reduced blood flow
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Aortic Stenosis

• Common
• May occur in isolation or in combination with
  other heart defects
• Aortic valve may be narrowed by congenital
  deformity
• bicuspid instead of tricuspid
• Stenosis may worsen with age
• thickening and calcification of the valve cusps
• Rheumatic fever

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Natural History

• Calcified Aortic Stenosis is a chronic
  progressive disease
• Without intervention once symptoms develop, the
  prognosis is dismal

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Symptoms and Signs

• Pulse
• slow rising
• small volume
• narrow pulse pressure
• Blood pressure is normal.
• Apex beat is heaving and displaced.
• Heart sounds
• Ejection systolic murmur
• Disappearance of 2nd heart sound in severe AS

• Often asymptomatic
• Angina
• Syncope
• Exertional dyspnoea
• Dizziness
• Sudden death

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Investigations

• Echo
• Key diagnostic tool
• Confirms presence of aortic stenosis
• Gradient and area of aortic valve outlet and flow
  rate
• Assesses degree of calcification
• LV function and thickness of wall
• Associated valvular disease

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Aortic Stenosis

• Pressure gradient across aortic valve in systole
• Defines degree of aortic valve obstruction
• Ventricular pressure required to deliver a
  certain cardiac output at the required perfusion
  pressure

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Aortic Stenosis

• Indications for surgery include
• Symptomatic severe AS
• Moderate/Severe AS and undergoing other cardiac
  surgery
• Asymptomatic patients with severe AS in certain
  situations
• AS with low gradient (lt40mmHg) and LV dysfunction
• Balloon valvuloplasty can be considered in
  symptomatic severe AS who are high risk for
  surgery

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Aortic Valve Replacement

• Definitive treatment for severe aortic stenosis
• Operative mortality
• 2-5 under 70 years
• 5-15 in older adults
• Factors associated with increased risk of
  operative mortality
• Older age
• Associated co-morbidities
• Female gender
• Higher functional class
• After successful valve replacement long term
  survival rates are close to those expected in
  control populations, symptoms less and quality of
  life improved

• Emergency operation
• LV dysfunction
• Pulmonary hypertension
• Coexisting coronary disease
• Previous bypass or valve surgery

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Medical Therapy

• Modification of atherosclerotic risk factors
• Avoidance of excessive exercise
• Controversial
• Conflicting data about beneficial effects of ace
  inhibitors and statins
• Ongoing trials
• Symptomatic patients require early surgery and no
  medical therapy is going to delay need for
  surgery
• Pts who are unsuitable for surgery may be treated
  with diuretics, ace inhibitors, beta blockers
• Mod-severe calcification of aortic valve
• if not meeting criteria for surgery currently and
  asymptomatic
• needs 6 monthly clinical assessment and 12
  monthly echos

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• Chronic Heart Failure

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Heart Failure

• Results from any structural or functional cardiac
  disorder that impairs the ability of the heart to
  function as a pump to support a physiological
  circulation
• Caused by
• Inappropriate work load
• Restrictive filling
• Myocyte loss

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Risk Factors for Heart Failure

• Coronary artery disease
• Hypertension
• Idiopathic dilated cardiomyopathy
• Valvular heart disease
• Other cardiomyopathy (e.g., sarcoidosis)
• Arrhythmia
• Anaemia
• Fluid volume overload with non-cardiac causes
• Thyroid disease (hypo- or hyperthyroidism)

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Heart failure

• Around 900 000 people in UK have heart failure
• Incidence and prevalence increases sharply with
  age
• Average age at first diagnosis 76 years
• 1 in 15 have heart failure aged 75-84 years
• 1 in 7 have heart failure aged 85 years and over

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Heart Failure

• Heart failure accounts for a total of 1 million
  in-patient bed days (2 of total NHS) and 5 of
  emergency medical admissions
• Poor prognosis 40 of patients diagnosed with
  heart failure die within a year and mortality is
  less than 10 per year thereafter

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Heart Failure

• Symptoms
• SOB, orthopnoea, paroxysmal noctural dyspnoea
• Swelling
• Signs
• Raised JVP
• Crackles on respiratory examination
• hypoxia
• Peripheral oedema
• Raised diastolic BP
• 3rd heart sound
• Pale, cold sweaty skin
• Displaced apex

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Monitoring

• Clinical assessment of functional capacity, fluid
  status, cardiac rhythm, cognitive and nutritional
  status
• Review of meds
• U Es
• Frequency of reviews depends on clinical
  condition but is required at least 6 monthly for
  stable patients with proven heart failure

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Investigations

• Echo
• To exclude valve disease
• Assess the systolic and diastolic function of the
  left ventricle
• Detect intra-cardiac shunts

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Treatment Goals

• Symptom reduction
• Improve functional ability
• Reduce hospitalisation and mortality
• Improve life expectancy
• Improve quality of life

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Treatment options

• Lifestyle
• Exercise, stop smoking, reduce alcohol intake
• Low salt diet
• Offer annual vaccination against influenza and
  vaccination against pneumococcal disease

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Ace Inhibitors

• All pts with heart failure due to left
  ventricular systolic dysfunction should be
  considered for treatment with an ACE inhibitor
• Use can reduce mortality by 20 with greater
  benefits in the higher risk patients
• Give before beta-blockade is introduced
• Improve symptoms, prevent worsening of heart
  failure and increase survival
• Titrated up in short intervals (e.g. every 2
  weeks) until optimal dose tolerated or target
  dose achieved
• E.g. Ramipril starting dose 2.5mg, target dose
  5mg bd or 10mg od

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ACE Inhibitors

• Possible problems
• Dizziness/symptomatic hypotension
• Cough
• Exclude other causes
• Consider use of angiotensin 11 receptor
  antagonists instead
• Renal impairment
• Some rise in urea, creatinine and K expected
  after initiation
• An increase of creatinine up to 50 above
  baseline or to 200 is acceptable
• An increase of K to less than 5.9 is acceptable
• Consider stopping other nephrotoxic meds
• If K gt6 or Cr gt 100 of baseline or gt 350
• Ace inhibitor should be stopped and specialist
  advice sought

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Beta-blockers

• Beta blockers licensed for use in heart failure
  (bisoprolol or carvedilol) should be initiated in
  patients with heart failure due to left
  ventricular systolic dysfunction after diuretic
  and ACE inhibitor therapy (regardless of whether
  symptoms persist or not)
• Start low dose and titrate up, with assessment of
  heart rate, BP and clinical status after each
  titration
• Improvement not apparent for 3 to 6 months
• U Es checked 1-2 weeks after change in dose
• If need to stop beta-blocker tail off gradually
  to avoid rebound ischaemia and arrhythmias
• Bisoprolol
• Starting dose 1.25mg od
• Target dose 10mg od

• Carvedilol
• Starting dose 3.125mg bd
• Target dose 25 50mg bd

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Beta-Blockers

• Problems
• If get worsening symptoms
• increase in dyspnoea, fatigue, oedema, weight
  gain
• Diuretic should be increased and consider halving
  dose of beta-blocker
• If low heart rate (lt50 beats per min)
• reduce dose of beta blocker and consider stopping
• Consider stopping other meds which may cause low
  heart rate
• ECG to check for heart block
• Seek specialist advice
• Asymptomatic low blood pressure
• does not usually require change in therapy
• Symptomatic hypotension
• Consider discontinuing drugs such as nitrates,
  calcium channel blockers and other vasodilators
• If no symptoms or signs of congestion consider
  reducing dose of diuretic

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Drugs

• Aldosterone antagonists
• Consider spironolactone 12.5mg 50mg once per
  day who remain moderately-severely symptomatic
  despite optimal therapy
• Need U Es monitored
• if hyperkalemia (but Klt 6) or renal impairment Cr
  up to 200 dose should be halved and then
  rechecked
• If hyperkalemia (Kgt 6) or renal impairment Cr gt
  200, spironolactone should be stopped
• Digoxin
• Indicated for worsening or severe heart failure
  due to left ventricular dysfunction despite ace
  inhibitor, beta-blocker and diuretic therapy
• or in patients with AF and any degree of heart
  failure

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Drugs

• Diuretics
• Used for relief of congestive symptoms and fluid
  retention in patients with heart failure and
  titrated up and down according to need
• Angiotensin 11 receptor antagonists
• Not licensed in UK for heart failure
• May provide alternative for patients intolerant
  to ACE inhibitors
• Amiodarone
• In consultation with specialist
• Reviewed regularly
• 6-monthly clinical review, LFTs, TFTs and review
  of side effects

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Drugs

• Anticoagulants
• Indicated for patients with heart failure and
  atrial fibrillation
• In patients with sinus rhythm and heart failure,
  anticoagulant should be considered for those with
  hx of thromboembolism, left ventricular aneurysm
  or intracardiac thrombus
• Aspirin
• 75-150mg per day for heart failure and
  atherosclerotic arterial disease

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Drugs

• Statins
• Patients with combination of heart failure and
  known atherosclerotic vascular disease
• Isosorbide/hydralazine combination
• Specialist initiation only in patients intolerant
  to ACE inhibitors or angiotensin 11 receptor
  antagonists
• Calcium channel blockers
• Amlodipine should be considered for treatment of
  co-morbid hypertension and/or angina in patients
  with heart failure
• Verapamil or diltiazem should be avoided

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Invasive Procedures

• Coronary Revascularisation
• Not routinely considered in patients with heart
  failure due to left ventricular systolic
  dysfunction unless have refractory angina
• Cardiac resynchronisation therapy
• In selected patients with left ventricular
  systolic dysfunction (left ventricular ejection
  fraction lt35), drug refractory symptoms and a
  QRS duration gt 120ms. Ongoing trials.
• Cardiac Transplantation
• Considered in patients with severe refractory
  symptoms or refractory cardiogenic shock

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Heart Failure not due to left ventricular
systolic dysfunction

• Valve disease
• Refer for specialist assessment and advice
  regarding follow up
• ACE inhibitor should not be initiated until valve
  disease has been assessed by a specialist
• Diastolic dysfunction
• Diagnosis and treatment should be made by a
  specialist
• Treatment with loop diuretics
• Other causes
• e.g. congenital heart disease, cardiomyopathies
  and specific heart muscle disease such as amyloid
• Require specialist input

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Specialist referral for heart failure

• Due to valve disease, diastolic dysfunction or
  other cause except left ventricular systolic
  dysfunction
• Co-morbidities
• COPD/asthma, renal impairment, anaemia, thyroid
  disease, peripheral vascular disease, urinary
  frequency, gout
• Angina, AF or other symptomatic arrhythmia
• Women who are pregnant or planning pregnancy
• Severe heart failure
• Heart failure that does not respond to treatment
• Where heart failure is unexplained
• Aged less than 60

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Grounds for admission

• Severe symptoms
• Dyspnoea or hypotension
• Acute myocardial infarction
• Severe complicating medical illness e.g.
  pneumonia
• Inadequate social support
• Failure to respond to treatment
• Uncontrolled arrhythmia

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• Key Points

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Aortic Stenosis

• Assess severity
• Consider referral
• Cautious about meds
• Avoid excessive exercise
• Regular monitoring

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Chronic Heart Failure

• Diuretics
• Ace Inhibitors
• Beta Blockers
• Spironolactone
• Other therapies

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• Any Questions?