Three main causes of Aortic Stenosis:
1. Congenital bicuspid aortic valve: age 50-60, men>women
2. (Acquired) Calcific aortic stenosis: age 70-80, men=women
3. (Acquired) Rheumatic aortic stenosis: middle-aged women>men, will also have mitral valve disease (note: rheumatic heart disease usually affects mitral, then tricuspid, then aortic in sequence)
Troponins
Troponins are a confirmatory test fo ACS in the setting of a history/clinical picture that suggests ACS. In other settings, it's a marker of myocyte necrosis but completely non-specific. It is only specific for ACS if ordered because the history suggested ACS.
Infective Endocarditis
Strep viridans does not generally cause large vegetations
- Staph and fungal infections cause large vegetations
- ECHO has low sensitivity
Acute versus Chronic Aortic Insufficiency (AI)
1. Chronic AI:
- LV has adapted by eccentric hypertrophy and dilatation to compensate for volume overload
- displaced apex beat
- long, loud, early diastolic decrescendo murmur, best heard at aortic area when the patient is seated and leans forward with breath held in expiration; often goes all the way to S1
- S1 is normal
- Wide pulse pressure, and related signs: waterhammer pulse, Corrigan's pulse, de Musset's sign, Quincke's sign (pulsations in the capillary nail bed), Duroziez's sign (systolic and diastolic murmurs heard over the femoral artery when it is gradually compressed with the stethescope)
2. Acute AI:
- equalization of aortic pressure with LV pressure because LV can't compensate acutely for all the extra volume = diastasis
- Premature S1 that is very soft (the massive reflux of blood from the aorta fills the left ventricle during diastole, increasing LVEDV and filling pressure, and closes the mitral valve prematurely), normal S2
- increased LA pressures leading to pulmonary edema (florid CHF)
- Very quiet and short early diastolic murmur
- Signs of vasoconstricted state, tachycardia, low sBP, dBP and MAP (and low stroke volume)
- pulse pressure not as wide
- Main causes: aortic dissection, aortic valve IE
