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Continue to follow him with serial echocardiography
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Follow him closer with shorter lengths of time between appointments
Have him follow up on an as-needed basis
Prescribe nitroglycerin tablets for his exertional angina
Refer him to a cardiac surgeon
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The patient in this vignette demonstrates the classic findings of aortic stenosis (AS). When AS becomes symptomatic, the aortic valve must be replaced by a cardiac surgeon. AS is a common cause of chronic heart failure in the elderly population. Mechanical wear, uni/bicuspid valve deformity, and rheumatic fever can all lead to AS. Although AS is often asymptomatic, when symptoms do appear, they often present with a triad of exertional angina, dyspnea, and syncope. Echocardiography is the gold standard and definitive way to diagnose AS. Grimard et al. discuss the diagnosis and treatment of AS. AS has been shown to affect approximately 3% of individuals over 65 years of age. Symptomatic patients that do not undergo valve replacement have an average overall survival rate of two to three years. Aortic valve replacement is the standard of care in patients with both symptomatic AS and positive echocardiography findings. Close monitoring and waiting is recommended for most asymptomatic patients. Manning reviews asymptomatic AS in the elderly. Because AS is the most common form of valvular heart disease, it is of utmost importance to correctly identify and appropriately treat it. The severity of AS dictates the frequency of which valvular monitoring by transthoracic echocardiography is needed. Be cognizant that patients with severe AS can still be asymptomatic since they may be subconsciously limiting their activities to avoid symptoms. Illustration A is a diagram demonstration of AS. Note the thickened leaflets causing aortic valve narrowing. Illustration B is a figure reviewing the different cardiac sounds commonly tested on the USMLE examinations. Illustration C is a gross specimen of stenosed aortic valve secondary to rheumatic heart disease. Incorrect Answers: Answers 1-3: These are inappropriate managements for someone with symptomatic aortic stenosis. Watchful waiting is appropriate only for asymptomatic patients. Answer 4: Nitroglycerin is commonly used for exertional angina that is secondary to an ischemic process.
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