Aortic Stenosis

Causes

The most common cause of aortic stenosis is age-associated degeneration and calcification of the aortic valve, which often causes symptoms in elderly patients.

In the past, this type of degeneration of the valve was most common in patients who had rheumatic fever during childhood. Currently, rheumatic fever is rarely a cause of aortic valve degeneration.

Symptoms

• Angina
• Dyspnea
• Orthopnea
• Peripheral edema
• Syncope
• Symptoms are often exertional.

Signs

• Cardiac auscultation: normal S1, soft A2 or single S2, loud S4, and a harsh crescendo-decrescendo systolic murmur at the right upper sternal border radiating to the carotids. Loudness of the murmur may diminish and length may increase as the stenosis becomes more severe.
• Classic delayed and diminished carotid upstrokes are often not present in the elderly because of the inelasticity of the vascular system in this population.
• Narrow pulse pressure may be noted.

Treatment

• ED management is focused on acute exacerbations of the symptoms of AS.
• Always, assess and address airway, breathing, and circulation.
• A patient presenting with uncontrolled CHF should be treated supportively with oxygen, cardiac and oximetry monitoring, intravenous access, loop diuretics, nitrates, morphine (as needed and tolerated), and noninvasive or invasive ventilatory support (as indicated).
• Vasodilators should be used judiciously in patients with AS, as they may cause a significant drop in blood pressure.