Aortic stenosis and aortic regurgitation aha american heart association new 2014

1. AS & AR
Abdelrahman Al-daqqa

2. • The most frequent valvular heart disease (~25%)
• The most frequent cardiovascular disease after
hypertension and coronary artery disease in
Europe and North America.
• Aortic stenosis is present in 1.3% of people aged
65–74 years and in 4% of people older than 85
years of age
• Aortic sclerosis; A degenerative disease of the
aortic valve most likely represents an early stage of
aortic stenosis. (> 65 years ~ 30%)
Aortic Stenosis - Prevalence

4. Symptoms

5. signs
• systolic, crescendo-decrescendo (i.e.,
'ejection') murmur.
• pulsus parvus et tardus
• Soft S2
• S4
• Precordial thrill
• Sustained PMI

7. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease

8. AR

9. Epidemiology
The prevalence of AR varied with age and disease
severity.
More than trace AR was unusual before age 50 and
then increased progressively.
●For mild AR, the prevalence was 3.7, 12.1, and 12.2
percent in men at ages 50 to 59, 60 to 69, and 70 to
83, respectively.
The comparable values in women were 1.9, 6.0, and
14.6 percent.

10. Aortic Regurgitation:
Etiology
• Any conditions resulting in
incompetent aortic leaflets
• Congenital
– Bicuspid valve
• Aortopathy
– Cystic medial necrosis
– Collagen disorders (e.g.
Marfan’s)
– Ehler-Danlos
– Osteogenesis imperfecta
– Pseudoxanthoma elasticum
• Acquired
– Rheumatic heart disease
– Dilated aorta (e.g.
hypertension..)
– Degenerative
– Connective tissue disorders
• E.g. ankylosing spondylitis,
rheumatoid arthritis, Reiter’s
syndrome, Giant-cell arteritis
)
– Syphilis (chronic aortitis)
• Acute AI: aortic dissection,
infective endocarditis,
trauma

11. Aortic Regurgitation:
Symptoms
• Dyspnea, orthopnea, PND
• Chest pain.
– Nocturnal angina >> exertional angina
– ( diastolic aortic pressure and increased LVEDP thus 
coronary artery diastolic flow)
• With extreme reductions in diastolic pressures (e.g. <
40) may see angina

12. Peripheral Signs of Severe
Aortic Regurgitation
• Quincke’s sign: capillary
pulsation
• Corrigan’s sign: water
hammer pulse
• Bisferiens pulse
• De Musset’s sign: systolic
head bobbing
• Mueller’s sign: systolic
pulsation of uvula
• Durosier’s sign: femoral
bruits
• Traube’s sign: pistol shot
femorals
• Hill’s sign:BP Lower
extremity >BP Upper
extremity by
– > 20 mm Hg - mild AR
– > 40 mm Hg – mod AR
– > 60 mm Hg – severe AR

13. Aortic Regurgitation:
Physical Exam
• Widened pulse pressure
– Systolic – diastolic = pulse pressure
• High pitched, blowing, decrescendo diastolic murmur at
LSB
• Best heard at end-expiration & leaning forward
• Hands & Knee position

14. Central Signs of Severe
Aortic Regurgitation
• Apex:
– Enlarged
– Displaced
– Hyper-dynamic
– Palpable S3
– Austin-Flint murmur
• Aortic diastolic
murmur
– length correlates with
severity (chronic AR)

15. Treatment
• The ACC/AHA guidelines > vasodilator therapy.
• The 2012 European Society of Cardiology
(ESC)/European Association for Cardio-Thoracic Surgery
(EACTS) guidelines recommend short-term use of
vasodilators and inotropic agents to improve the
condition of patients with severe heart failure before
proceeding with valve surgery.
• Antibiotic Prophylaxis :under current ACC/AHA
guidelines, the prophylactic use of antibiotics prior to
dental procedures is no longer routinely recommended
for all patients with AR.

16. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease