Aortic stenosis: hypotension rx
Pretest
Question 1
True or False
Recommendations for aortic valve replacement (AVR) include
1. Asymptomatic severe AS with LV dysfunction.
2. abnormal response to exercise such as hypotension.
3. This will be a class Ila indication.
4. weight of evidence is in favor of usefulness.
Keyword
In Aortic Stenosis (AS), there is a long latent period of increasing obstruction during which an asymptomatic patient has a normal life-span. However once angina, syncope or heart failure develops, survival is reduced.
If the aortic valve is not replaced, approximately 50% will be dead within 5 years after angina develops, 50% will be dead within 3 years after syncope develops and 50% will be dead within 2 years after heart failure develops.
Symptomatic valvular aortic stenosis is associated with poor prognosis, hence surgical intervention is required at symptom onset.
Even mild symptoms warrant prompt surgical intervention when severe aortic stenosis is present.
The types of intervention can be balloon aortic valvotomy (BAV) or aortic valve replacement (AVR).
The timing of intervention is based on
1.Symptomatic status and
2.Aortic velocity measured by echo Doppler or by gradients measured by Doppler or cardiac catheterization.
In patients with baseline aortic velocity less than 3 m/sec. only 8% developed symptoms per year, where as 40% in those with aortic velocity > 4 m/sec became symptomatic.
It was found that optimal time for intervention was when the symptoms develop.
Recommendations for AVR
1.Symptomatic severe AS
2.Asymptomatic severe AS with LV dysfunction or abnormal response to exercise such as hypotension will be a class Ila indication (weight of evidence is in favor of usefulness)
3.Asymptomatic severe AS with
a. Ventricular tachycardia
b. Marked LVH
c. Valve area < 0.6 sq.cm
All of them will only be class llb indication as per ACC/AHA guidelines. (usefulness /efficacy is less well established by evidence /opinion)
4.AVR is not recommended for asymptomatic severe AS with none of the features mentioned above.
AVR is recommended in symptomatic severe AS or in patients with asymptomatic severe AS with LV dysfunction.
http://www.emexcardio.org/artikel_apicon1.htm
Post test
Question 1
True or False
Recommendations for aortic valve replacement (AVR) include
1. Asymptomatic severe AS with LV dysfunction.
2. abnormal response to exercise such as hypotension.
3. This will be a class Ila indication.
4. weight of evidence is in favor of usefulness.
Answer:
TTTT