Review Question - QID 204155

Isolated aortic stenosis in an elderly patient is most likely caused by age-related idiopathic sclerocalcific changes. With longstanding aortic stenosis, the patient may develop left ventricular hypertrophy detectable on EKG.

Aortic stenosis is a major cause of chronic heart failure in elderly patients and is often due to senile calcification. Younger patients may also present with aortic stenosis due to underlying congenital valvular defects or rheumatic fever. Aortic stenosis causes a crescendo-decrescendo murmur during systole. The intensity of the murmur is dependent on the difference in pressures between the left ventricle and the aorta. As the condition worsens, the intensity of the murmur peaks later in systole. Late in the disease the A2 component (of S2) may also be diminished. When symptomatic, aortic stenosis may cause the triad of syncope, angina, and heart failure. Diagnosis can be confirmed with echocardiography. Treatment is purely surgical with valve replacement or balloon valvuloplasty.

Grimard and Larson discuss aortic stenosis - diagnosis and treatment. Aortic stenosis is the most common valve disease in developed countries affecting 3% of patients older than 65. Overall survival in symptomatic people without aortic valve replacement is 2-3 years. During the asymptomatic latent period, left ventricular hypertrophy and increased preload compensate for the increase in afterload caused by the valvular abnormality.

Schillaci et al discuss the role of EKG in the diagnosis of left ventricular hypertrophy in hypertension. It remains the first line method for detection. It predicts a several fold increase in age and risk factor adjusted cardiovascular morbidity and mortality in asymptomatic patients with essential hypertension. Cornell voltage product (S in V3 + R in aVL > 2.8 mV in men or > 2.0 mV in women) and Perugia criterion (one of S in V3 + R in aVL > 2.4 mV in men or > 2.0 mV in women, typical strain pattern, or Romhilt-Estes point score > or = 5) allow for detection of left ventricular hypertrophy in a higher proportion of patients carrying cardiovascular risk factors.

Image A depicts an EKG remarkable for left ventricular hypertrophy. Note the prominent voltage in the left precordial leads.

Incorrect Answers:
Answers 1 and 4: Bicuspid valve is another cause of aortic stenosis but is often seen in younger patients.
Answers 2 and 5: Rheumatic heart disease may cause aortic stenosis but the EKG does not show atrial fibrillation or myocardial ischemia.