CURRENT Essentials of Critical Care.pdf

Chapter 9 Cardiology 117■■■Aortic Valvular Heart DiseaseEssentials of Diagnosis• Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, cough, syncope,chest pain; signs and symptoms differ between acute andchronic lesions• Aortic stenosis (AS): angina, syncope, pulsus parvus et tardus,harsh crescendo-decrescendo systolic murmur; may be due torheumatic heart disease, congenital abnormalities, calcification• Aortic regurgitation (AR): wide pulse pressure, water-hammerpulse, Quincke pulse, Duroziez sign, early diastolic murmur;may be due to leaflet disorders (endocarditis, myxomatous degeneration,bicuspid valve) or dilated aortic root (syphilis, aorticdissection, connective tissue disorders)• Echocardiogram essential in confirming and assessing diagnosisDifferential Diagnosis• Aortic stenosis: mitral regurgitation, hypertrophic cardiomyopathy(HCM), ventricular septal defect (VSD)• Aortic regurgitation: mitral stenosis, pulmonary hypertensionwith Graham-Steele murmurTreatment• Aortic stenosis: no medical management; when severe, requiressurgery or valvuloplasty (transiently effective); vasodilatordrugs may cause severe hypotension• Aortic regurgitation: diuretics with sodium and fluid restriction;digoxin; preload and afterload reduction with ACE inhibitors,hydralazine plus nitrates, nitroprusside• Infective endocarditis prophylaxis• Cardiac catheterization often necessary prior to surgery• Surgical valve repair or replacement ideally indicated for allsymptomatic patients■ PearlSymptomatic aortic stenosis confers a poor prognosis with the averagetime to death often limited to only a few years: with angina—3years, syncope—3 years, and pulmonary edema—2 years.ReferenceBonow RO et al: ACC/AHA guidelines for the management of patients withvalvular heart disease. J Am Coll Cardiol 1998;32:1486. [PMID: 9809971]