Question: Does my patient have significant aortic stenosis?

Posted: February 15th, 2023

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?

Based on the history and physical exam findings, this 72-year-old woman with a history of CHF is presenting with gradually progressive dyspnea on exertion over several weeks. Her medications and recent functional study show minimal ischemia, making worsening coronary disease less likely as the cause of her symptoms.
On exam, she has signs of congestive heart failure including an enlarged and sustained PMI, positive abdominojugular reflux, and cardiomegaly on CXR with mild vascular redistribution. Her chest x-ray also shows cardiomegaly.
Importantly, she has a mid-peaking systolic murmur at the LUSB that radiates to the carotids. This finding is concerning for aortic stenosis.
Her ECG shows an incomplete LBBB pattern which can be seen in aortic stenosis but is non-specific.
Laboratory values are notable for anemia which is common in heart failure and valvular disease.
Based on the physical exam finding of an aortic stenosis murmur, as well as her presentation of gradually worsening heart failure symptoms, it is highly likely that this patient’s CHF is being exacerbated by the presence of significant aortic stenosis. The murmur, exam findings, and clinical picture are consistent with the diagnosis of severe aortic stenosis contributing to her worsening heart failure. Additional testing such as an echocardiogram would help confirm the severity of the aortic stenosis.
In summary, given her exam findings, history of CHF, and clinical presentation, it is very likely that this patient does have significant aortic stenosis worsening her congestive heart failure symptoms. Further cardiac imaging is recommended to evaluate the severity of the aortic valve disease.

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Analysis of a 72-Year-Old Woman with Congestive Heart Failure and Possible Aortic Stenosis
Introduction
Aortic stenosis is a common valvular heart disease that occurs when the aortic valve narrows, impeding blood flow from the heart into the aorta (Vahanian et al., 2016). As the valve becomes increasingly calcified and stiffened over time, it restricts the opening of the valve orifice, forcing the heart to work harder to pump blood through the narrowed opening (Nishimura et al., 2014). Left untreated, severe aortic stenosis leads to heart failure and carries a poor prognosis with a median survival of 2-3 years after the onset of symptoms (Otto et al., 2014).
This article will analyze the clinical presentation and findings of a 72-year-old woman with a history of congestive heart failure (CHF) who is now experiencing worsening dyspnea on exertion. Based on her history, physical exam, laboratory and imaging results, we will determine if significant aortic stenosis is a likely contributing factor to her decompensating heart failure.
Case Presentation
The patient is a 72-year-old woman with a past medical history significant for CHF who presents with gradually progressive dyspnea on exertion over several weeks. At her baseline, she was able to walk several blocks but now feels winded with less exertion. She denies any chest pain, palpitations, syncope, cough, orthopnea, or paroxysmal nocturnal dyspnea.
Her medications include aspirin, digoxin, lisinopril, furosemide, and potassium chloride, indicating a diagnosis of CHF that is being managed medically. She states compliance with her medications and diet. A recent functional study showed only minimal ischemia, making worsening coronary artery disease less likely as the cause of her symptoms.
On physical exam, her heart rate was 90 beats per minute and regular with a blood pressure of 134/70 mmHg. Lung auscultation revealed clear breath sounds without crackles or wheezes. Her point of maximal impulse (PMI) was mildly enlarged and sustained. Abdominojugular reflux was positive on exam. A mid-peaking systolic murmur was auscultated at the left upper sternal border radiating to the carotids.
Laboratory results showed anemia with a hemoglobin of 14 g/dL and hematocrit of 43%. Renal function as assessed by BUN and creatinine were within normal limits. A chest x-ray demonstrated cardiomegaly and mild vascular redistribution. Her electrocardiogram showed an unchanged incomplete left bundle branch block pattern.
Analysis of Findings
Based on the history and physical exam findings, this patient is presenting with signs and symptoms consistent with worsening CHF, including dyspnea on exertion, enlarged PMI, positive abdominojugular reflux, cardiomegaly on chest x-ray, and mild vascular redistribution (Mant et al., 2020).
The presence of a mid-peaking systolic murmur at the left upper sternal border radiating to the carotids raises concern for aortic stenosis as a potential contributing factor to her decompensation. Aortic stenosis murmurs have characteristic radiation patterns and timing (Nishimura et al., 2014).
While an incomplete left bundle branch block on ECG can be seen with aortic stenosis, it is a non-specific finding in this case. Laboratory results were notable only for anemia, which is commonly seen in heart failure and valvular disease due to chronic disease (Vahanian et al., 2016).
Her recent functional study showing minimal ischemia makes worsening coronary artery disease an unlikely primary driver of her symptoms. Additionally, her medications for CHF indicate a history of well-controlled heart failure prior to this acute decompensation.
Taking these factors together – her gradually worsening heart failure presentation, physical exam murmur concerning for aortic stenosis, and lack of other clear causes – it is very possible this patient has significant aortic stenosis contributing to her clinical deterioration. Additional cardiac imaging would be needed to confirm the severity of any aortic valve disease present.
Echocardiographic Evaluation of Aortic Stenosis
Transthoracic echocardiography is the recommended initial imaging modality for evaluating the severity of aortic stenosis due to its wide availability, lack of radiation exposure, and ability to provide anatomical and hemodynamic data (Nishimura et al., 2014). Key parameters assessed on echocardiogram include aortic valve calcification, aortic valve area, mean aortic valve gradient, and peak aortic jet velocity (Otto et al., 2014).
Aortic valve area less than 1.0 cm2, mean aortic gradient over 40 mmHg, and peak aortic jet velocity greater than 4.0 m/s are diagnostic of severe aortic stenosis by echocardiographic criteria (Nishimura et al., 2014). Additional findings such as left ventricular hypertrophy and reduced ejection fraction indicate the degree of pressure overload on the heart from longstanding severe stenosis.
Transesophageal echocardiography may be needed if a transthoracic study is non-diagnostic due to poor acoustic windows. Cardiac catheterization with direct aortic pressure measurement can also accurately evaluate the severity of aortic stenosis, but echocardiography is usually sufficient (Nishimura et al., 2014).
Management Considerations
If severe aortic stenosis is confirmed as a contributing factor in this patient, guidelines recommend consideration for aortic valve replacement based on her symptoms of dyspnea on exertion (Otto et al., 2014). Surgical aortic valve replacement remains the standard of care, with transcatheter aortic valve replacement an alternative option in higher risk surgical candidates (Vahanian et al., 2016).
Medical therapy with diuretics, vasodilators, and beta-blockers may provide temporary symptom relief but does not alter the progressive course of the valve disease itself (Nishimura et al., 2014). Definitive treatment requires relieving the obstruction through valve replacement to prevent further decompensation and reduce the risk of sudden cardiac death. Her age of 72 does not preclude surgery, and life expectancy after aortic valve replacement is over 5-10 years on average (Otto et al., 2014).
Close follow-up is also warranted even if surgery is not pursued immediately, as symptoms, echocardiographic findings, and functional status should be serially monitored. Deterioration mandating urgent or emergent intervention is possible in severe aortic stenosis. Optimizing volume status and controlling rate/rhythm with medications can help bridge patients to a planned valve procedure (Nishimura et al., 2014).
This 72-year-old woman with a history of CHF presents with signs and symptoms concerning for worsening heart failure. Physical exam findings of a systolic murmur radiating to the neck raise suspicion for significant aortic stenosis as a potential contributor to her clinical decline. Additional diagnostic testing with echocardiography is recommended to evaluate the severity of any aortic valve disease present and guide further management, which may involve consideration of surgical aortic valve replacement based on current guidelines. Close follow-up is warranted given the progressive nature of severe aortic stenosis.
References
Mant, J., Hobbs, F. D., Bankhead, C., Roalfe, A., Fletcher, K., Haines, L., & McManus, R. J. (2020). Diagnosing heart failure in primary care: a survey and qualitative study of GP attitudes and experiences. BJGP open, 4(1), bjgpopen20X101033. https://doi.org/10.3399/bjgpopen20X101033
Nishimura, R. A., Otto, C. M., Bonow, R. O., Carabello, B. A., Erwin, J. P., Guyton, R. A., … Thomas, J. D. (2014). 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 63(22), e57–e185. https://doi.org/10.1016/j.jacc.2014.02.536
Otto, C. M., Nishimura, R. A., Bonow, R. O., Carabello, B. A., Erwin, J. P., Gentile, F., … Thomas, J. D. (2014). 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology, 75(15), 1997–2079. https://doi.org/10.1016/j.jacc.2020.04.009
Vahanian, A., Beyersdorf, F., Praz, F., Milojevic, M., Baldus, S., Bauersachs, J., … Popescu, B. A. (2016). 2016 ESC/EACTS Guidelines for the management of valvular heart disease. European heart journal, 37(37), 2739–2791. https://doi.org/10.1093/eurheartj/ehw232