Cardiology Curriculum.docx

[[Imaging]](#imaging) [[Coronary artery disease]](#coronary-artery-disease) [[Valvular heart disease]](#valvular-heart-disease) [[Rhythm disorders]](#rhythm-disorders) [[Heart failure]](#heart-failure) [[Acute cardiovascular care]](#acute-cardiovascular-care) [[Prevention, rehabilitation, and...

[[Imaging]](#imaging) [[Coronary artery disease]](#coronary-artery-disease) [[Valvular heart disease]](#valvular-heart-disease) [[Rhythm disorders]](#rhythm-disorders) [[Heart failure]](#heart-failure) [[Acute cardiovascular care]](#acute-cardiovascular-care) [[Prevention, rehabilitation, and sports]](#prevention-rehabilitation-and-sports) [[Cardiac patients in other settings]](#cardiac-patients-in-other-settings) Imaging ------- ### Assess a patient using one or multiple imaging modalities - - - - - - - - - - - - - - - - - - - - - - - ### Assess a patient using echocardiography - - - - - - - - - - ### Assess a patient using cardiac magnetic resonance - - - - - - - - - - - - ### Assess a patient using cardiac computed tomography - - - - - - - - - ### Assess a patient using nuclear techniques - - - - - - - - - - - - - - - - - - Coronary artery disease ----------------------- ### Manage a patient with symptoms suggestive of coronary artery disease - - - - +-----------------------------------+-----------------------------------+ | Location | located in the chest, near the | | | sternum, but may be felt anywhere | | | from the epigastrium to the lower | | | jaw or teeth, between the | | | shoulder blades, or in either arm | | | to the wrist and fingers. | +===================================+===================================+ | Character | Pressure, tightness, or | | | heaviness; sometimes strangling, | | | constricting, or burning. It may | | | be useful to ask the patient | | | directly about the presence of | | | 'discomfort' as many do not feel | | | 'pain' or 'pressure' in their | | | chest. | +-----------------------------------+-----------------------------------+ | Duration/ relationship to | brief---\ - - - - - - - - - - - - - - - - - - - CAD Consortium risk score - - Risk stratification Scores +-----------------------------------+-----------------------------------+ | ACS | European Society of Cardiology | | | suggests an algorithm for the | | | evaluation of patients with acute | | | coronary syndrome probability. | | | | | |  | | | | | | The pain presence raises | | | suspicion of acute coronary | | | syndrome. | | | | | | The ECG may show ST segment | | | elevation, normal pattern or | | | atypical abnormalities. | | | | | | - - - | | | | | | Depending on the biochemical | | | markers (troponin) risk | | | stratification can be made and | | | therapeutic management can be | | | guided. | | | | | | Afterwards, risk assessment will | | | be made for secondary prevention. | +===================================+===================================+ | Stable Angina | | +-----------------------------------+-----------------------------------+ ### Manage a patient with acute coronary syndrome - - - - +-----------------------------------+-----------------------------------+ | Spontaneous coronary artery | - - - | | dissection | | | | - | +===================================+===================================+ | Coronary artery embolism | - - | +-----------------------------------+-----------------------------------+ | Coronary vasospasm | - - - - - | | | | | | - - - - | | | | | | - - | +-----------------------------------+-----------------------------------+ | Coronary Artery bridging | - - - - | +-----------------------------------+-----------------------------------+ | Stress induced cardiomyopathy | - - - | | | | | | - - - - | +-----------------------------------+-----------------------------------+ - - - - - - -  - - +-----------------------------------+-----------------------------------+ | ECG | - - - | +===================================+===================================+ | Troponin | - - - | | | | | |  | +-----------------------------------+-----------------------------------+ | Other biomarkers | - | +-----------------------------------+-----------------------------------+ | Echocardiography | - - | | | | | | - - | +-----------------------------------+-----------------------------------+ | Other imaging techniques | - - | | | | | | - - - - | | | | | | - - - - - | | | | | | - - - | | | | | | - - | +-----------------------------------+-----------------------------------+ - - +-----------------------------------+-----------------------------------+ | | Analgesics | +===================================+===================================+ | Properties | GTN - sublingual, buccal | | | | | | IV opioids (superior to | | | paracetamol) | +-----------------------------------+-----------------------------------+ | Effects | | +-----------------------------------+-----------------------------------+ | Indications | | +-----------------------------------+-----------------------------------+ | Contraindications | Nitrates | | | | | | - | +-----------------------------------+-----------------------------------+ | Side Effects | Morphine | | | | | | - - - | +-----------------------------------+-----------------------------------+ Anti-ischemics ------------------- ---------------- Properties Effects Indications Contraindications Side Effects Anticoagulants ------------------- -------------------------------------------- Properties UFH, enoxaparin, bivalirudin, Fonadparinux Effects Indications Contraindications Side Effects Fibrinolytics ------------------- --------------- Properties Effects Indications Contraindications Side Effects +-----------------------------------+-----------------------------------+ | | Platelet Inhibitors | +===================================+===================================+ | Properties | Aspirin | | | | | | P2Y12 receptor inhibitors | | | | | | GP iib/iiia receptor inhibitors | +-----------------------------------+-----------------------------------+ | Effects | | +-----------------------------------+-----------------------------------+ | Indications | | +-----------------------------------+-----------------------------------+ | Contraindications | | +-----------------------------------+-----------------------------------+ | Side Effects | | +-----------------------------------+-----------------------------------+ Statins ------------------- --------- Properties Effects Indications Contraindications Side Effects Other: - - - - - ### Manage a patient with chronic coronary syndrome - Epidemiology - Risk Factors - - - - - - Atherosclerosis is the development of lipid-rich plaques in the arterial wall. Plaque development is the result of an inflammatory process that can involve not only lipids but also altered smooth muscle cells, matrix proteins, calcification, necrosis, and haemorrhage. Plaques do not occur uniformly through the arterial tree and tend to occur at bends, branch points, and other areas of turbulent flow. A traditional model suggests two means of plaque progression. Large thick-walled plaques are thought to slowly obstruct the lumen of coronary arteries, thereby causing decreased perfusion and chronic intermittent exertional symptoms when they reach 70% to 80% stenosis. Thin-walled \'vulnerable plaques\' may not cause meaningful obstruction until the wall is disrupted, at which point acute haematoma and thrombus formation cause sudden myocardial infarction by occluding the arterial lumen locally or embolising distally into the coronary circulation. This model explains two clinically important phenomena: 1) myocardial infarction may occur in patients at anatomical sites without baseline flow limitation; 2) therapies that reduce chronic intermittent angina (improve flow) may be different from those that reduce ischaemic heart disease mortality (stabilise plaque, prevent thrombosis). The actual process is more varied and complex. In many cases arteries can expand outwards, meaning that plaque size may not correlate with luminal stenosis, which in turn may not correlate with functional flow limitation.Additionally, plaque development is not linear; plaques may move repeatedly through development, regression, and erosion/rupture. - The coronary tree is a reactive network of vessels that respond to stimuli such as exercise and stress. During exercise, for example, the normal response of the coronary tree is vasodilatation to increase coronary flow and meet the demands of the heart. A functional endothelium plays a central role in this responsive process, synthesizing and excreting potent vasodilatory molecules, such as nitric oxide (NO) - Myocardial viability refers to a phenomenon in which dysfunctional myocardium, due to acute or chronic ischemia, retains its potential to recover systolic function after revascularization. The myocardial insults secondary to acute or chronic ischemia lead not only to irreversible damage to the myocardium but also adaptive responses in which the myocardium stays in a latent state in an ischemic milieu with the potential to recover upon revascularization A myocardium that is dysfunctional due to ischemia but potentially salvageable upon revascularization is viable. Viable myocardium can be 'stunned' or 'hibernating.' This is believed to be due to the adaptive response of the myocardium to the ischemic milieu with the downregulation of its metabolism and contractility. Repetitive ischemia lasting for a lesser duration causes a temporary loss of contraction with a potential for recovery in the function of viable myocardium in days to weeks, an entity called 'myocardial stunning. Chronic stunning is the phenomenon where repetitive episodes of reversible ischemia before myocardial function normalizes lead to chronic myocardial dysfunction. Myocardial hibernation is an adaptation to chronic ischemia with only a little cell death in which myocardial segments supplied by the coronary artery with fixed stenosis remain noncontractile due to the downregulation of cellular metabolism but retain their potential to recover partially or entirely upon revascularization. It is a state of chronic left ventricular systolic dysfunction resulting from the adaptation of ischemic myocardium to critically reduced perfusion, thus establishing a new balance between reduced flow and function. -  - With aggressive lifestyle modification and guideline-directed medical therapy, patients can expect a reduction in anginal symptoms. With guideline-directed management, 58% of patients can expect to be free of angina within 1 year. Ischaemic heart disease is a dynamic process. Even with aggressive medical management and lifestyle changes, some patients may experience recurrence or worsening of anginal symptoms due to progression of atherosclerotic disease. Upwards titration of anti-anginal medications may resolve these symptoms; however, some patients may require revascularisation to improve anginal symptoms and exercise tolerance. - +-----------------------------------+-----------------------------------+ | Blood Tests | - - | +===================================+===================================+ | ECG - Rest, ambulatory | - - - - - - | +-----------------------------------+-----------------------------------+ | Stress Test | - - | +-----------------------------------+-----------------------------------+ | Echo | - - - - | +-----------------------------------+-----------------------------------+ | CTCA | - - - - | +-----------------------------------+-----------------------------------+ | CMRI | - - - | +-----------------------------------+-----------------------------------+ | Angio | - - | +-----------------------------------+-----------------------------------+ | CXR | - | +-----------------------------------+-----------------------------------+ - In probability theory and statistics, Bayes\' theorem (alternatively Bayes\' law or Bayes\' rule), named after Thomas Bayes, describes the probability of an event, based on prior knowledge of conditions that might be related to the event.For example, if the risk of developing health problems is known to increase with age, Bayes\' theorem allows the risk to an individual of a known age to be assessed more accurately by conditioning it relative to their age, rather than simply assuming that the individual is typical of the population as a whole. BAYES\' THEOREM\' can be used to calculate the probability of coronary artery disease based on clinical data and multiple noninvasive test results. Pretest probabilities of disease are assigned based on clinical data and the equation is used to calculate posttest probabilities after multiple sequential tests. Diagnostic testing is most useful when the likelihood is intermediate. When likelihood is high, a large number of patients need to be studied to identify the few patients that do not have disease, and a negative test result can seldom rule out the presence of obstructive CAD (i.e. the negative predictive value is low). When the likelihood is low, a negative test can rule out the disease, but the lower the likelihood, the higher the likelihood of a falsepositive test (i.e. a positive test in the absence of obstructive CAD). In patients at the extreme ends of the probability range, it is therefore reasonable to refrain from diagnostic testing, and assume that the patient does or does not have obstructive CAD based on clinical evaluation alone. The likelihood of obstructive CAD is influenced by the prevalence of the disease in the population studied, as well as by clinical features of an individual patient. A simple predictive model can be used to estimate the pre-test probability (PTP) of obstructive CAD based on age, sex, and the nature of symptoms. - Invasive functional assessment should complement ICA, especially in patients with coronary stenoses of 50 - 90% or multivessel disease, given the frequent mismatch between the angiographic and haemodynamic severities of coronary stenoses. Systematic integration of ICA with FFR has been shown to result in changes to the management strategies of 30 - 50% of patients undergoing elective ICA  - A. There is no universal definition of an optimal treatment in patients with CCS, and drug therapies must be adapted to each patient's characteristics and preferences.  B. -  - Revascularization by either PCI or CABG also aims to effectively eliminate myocardial ischaemia and its adverse clinical manifestations among patients with significant coronary stenosis, and to reduce the risk of major acute cardiovascular events including MI and cardiovascular death.  - - - +-----------------------------------+-----------------------------------+ | Hypertension | It is recommended that office BP | | | is controlled to target values: | | | systolic BP 120 - 130 mmHg in | | | general and systolic BP 130 - 140 | | | mmHg in older patients (aged \65 | | | years) | | | | | | In hypertensive patients with a | | | recent MI, betablockers and RAS | | | blockers are recommended | | | | | | In patients with symptomatic | | | angina, betablockers and/or CCBs | | | are recommended | | | | | | The combination of ACE inhibitors | | | and ARBs is not recommended | +===================================+===================================+ | Valvular | ICA is recommended before valve | | | surgery and for any of the | | | following: history of CVD, | | | suspected myocardial ischaemia, | | | LV systolic dysfunction, in men | | | \>40 years of age and | | | postmenopausal women, or one or | | | more cardiovascular risk factors | | | | | | ICA is recommended in the | | | evaluation of moderate-to-severe | | | functional mitral regurgitation. | | | | | | Coronary CTA should be considered | | | as an alternative to coronary | | | angiography before valve | | | intervention in patients with | | | severe valvular heart disease and | | | low probability of CAD | | | | | | PCI should be considered in | | | patients undergoing transcatheter | | | aortic valve implantation and | | | coronary artery diameter stenosis | | | \>70% in proximal segments. | | | | | | In severe valvular heart disease, | | | stress testing should not be | | | routinely used to detect CAD | | | because of the low diagnostic | | | yield and potential risks. | +-----------------------------------+-----------------------------------+ | Cancer | Treatment decisions should be | | | based on life expectancy, | | | additional comorbidities such as | | | thrombocytopenia, increased | | | thrombosis propensity, and | | | potential interactions between | | | drugs used in CCS management and | | | antineoplastic agents | | | | | | If revascularization is indicated | | | in highly symptomatic patients | | | with active cancer and increased | | | frailty, the least invasive | | | procedure is recommended. | +-----------------------------------+-----------------------------------+ | Diabetes | Risk factor (BP, LDL-C, and | | | HbA1c) control to targets is | | | recommended in patients with CAD | | | and diabetes mellitus | | | | | | In asymptomatic patients with | | | diabetes mellitus, a periodic | | | resting ECG is recommended for | | | cardiovascular detection of | | | conduction abnormalities, AF, and | | | silent MI. | | | | | | ACE inhibitor treatment is | | | recommended in CCS patients with | | | diabetes for event prevention. | | | | | | The sodium-glucose co-transporter | | | 2 inhibitors empagliflozin, | | | canagliflozin, or dapagliflozin | | | are recommended in patients with | | | diabetes and CVD | | | | | | A glucagon-like peptide-1 | | | receptor agonist (liraglutide or | | | semaglutide) is recommended in | | | patients with diabetes and CVD | | | | | | In asymptomatic adults (age \>40 | | | years) with diabetes, functional | | | imaging or coronary CTA may be | | | considered for advanced | | | cardiovascular risk assessment | +-----------------------------------+-----------------------------------+ | CKD | It is recommended that risk | | | factors are controlled to target | | | values | | | | | | It is recommended that special | | | attention is paid to potential | | | dose adjustments of renally | | | excreted drugs used in CCS. | | | | | | It is recommended that the use of | | | iodinated contrast agents is | | | minimized in patients with severe | | | CKD and preserved urine | | | production to prevent further | | | deterioration. | +-----------------------------------+-----------------------------------+ | Elderly | It is recommended that particular | | | attention is paid to side effects | | | of drugs, intolerance, and | | | overdosing in elderly patients. | | | | | | The use of DES is recommended in | | | elderly patients | | | | | | Radial access is recommended in | | | elderly patients to reduce | | | access-site bleeding | | | complications | | | | | | It is recommended that diagnostic | | | and revascularization decisions | | | are based on symptoms, the extent | | | of ischaemia, frailty, life | | | expectancy, and comorbidities | +-----------------------------------+-----------------------------------+ ### Assess a patient using coronary angiography - - - -  - Radiation Physics - - - - - - - - - - - - - -  Safety Regulations - - - - - - -  - - - - - - - - -  - A. In the UK, the most commonly used pre-shaped catheters are the Judkins Left 4 and Judkins Right 4 (known as the JL4 and JR4 respectively), used to image the left and right coronary arteries, and the pigtail catheter, used for left ventriculography. The diameter of catheters is measured in French gauge (Fr); catheters between 4Fr (0.053\") and 8 Fr (0.105\") are commonly used. The JL4 catheter will almost invariably cannulate the left coronary ostium without manipulation. In patients with large aortic roots (large, hypertensive patients), the JL5 (with a larger curve) may be needed, and, conversely, a smaller root may need a smaller catheter curve, the JL3.5. The JR4 catheter is introduced to the aortic root, until it lies 1--2 cm above the aortic valve. B. Disposable pressure transducers are used to obtain a precise and continuous measurement of physiological pressures. Intravascular and intracardiac pressure transducers detect the pressure generated in various areas of the cardiovascular system and convert that pressure wave into an electrical signal, which is transmitted to the monitoring equipment for representation as a waveform on the oscilloscope. C. For the injection of contrast medium through a cardiac catheter, high pressures are needed, making the use of a power injector. D. Coronary angiography has evolved to use the smallest-bore catheters, with many diagnostic angiograms using 5F or even 4F catheters to decrease vascular complications. However, proper evaluation of pressures during a complex hemodynamic catheterization is optimally performed with larger-bore catheters that yield high-quality hemodynamic data. To obtain proper hemodynamic tracings, 6F or even 7F catheters may be required if the smaller catheters do not produce high-quality pressure contours. Catheters with side holes should be used to measure ventricular pressures. Catheters with end holes should be used to measure wedge pressures. The use of high-fidelity manometer-tipped catheters might also need to be considered in those instances when intricate analysis of diastolic filling contours is required. If fluid-filled catheters are used, it is important to choose the shortest extension tubing possible to obtain optimal pressure contours. For this reason, the use of the coronary manifold with its long extenders that degrade pressure tracings should be avoided.The invasive cardiologist must continually assess pressure contours throughout the study. Overdamped and underdamped pressure tracings and whip artifact should be anticipated and corrected. Formation of small thrombi in catheters can cause significant changes in pressure contour, especially in catheters with small internal diameters. Thus, all catheters should undergo intermittent flushing with heparinized saline throughout their use, with constant monitoring of the pressure contour. Rebalancing the zero baseline should also be done while the pressures are being collected. Catheter entrapment will produce erroneous pressure measurements and can be identified by unusual pressure contours. Slight changes in position of a catheter may cause abnormal pressure contours, particularly if catheters with multiple side holes are placed straddling a valve - +-----------------------+-----------------------+-----------------------+ | | Advatanages | Disadvantages | +=======================+=======================+=======================+ | Femoral Artery | - | Risks of: | | | | | | | | - - - - - | +-----------------------+-----------------------+-----------------------+ | Radial Artery | - - - - | Risks of: | | | | | | | | - - - - - - | | | | - - | +-----------------------+-----------------------+-----------------------+ | Brachial artery | - | - - | +-----------------------+-----------------------+-----------------------+ - +-----------------------------------+-----------------------------------+ | Radial Artery Spasm | careful patient selection, | | | avoiding small and | | | difficult-to-palpate | | | | | | radial arteries | | | | | | adequate patient sedation if | | | required---pain provokes spasm | | | | | | the use of a 'cocktail' of drugs | | | introduced directly into the | | | radial artery. A variety of | | | different regimens have been | | | described. We use 1 mg isosorbide | | | dinitrate, 2.5 mg verapamil, and | | | 2500 U heparin made up to 10 mL | | | with normal saline. Repeated | | | doses of nitrates or verapamil | | | (up to 5 mg) given directly into | | | the sheath or in the catheter may | | | be required | | | | | | shorter sheaths may be better | | | tolerated | | | | | | some sheaths have a hydrophilic | | | coating to try to reduce spasm, | | | and for less discomfort on | | | removal | | | | | | always use a guide wire to | | | straighten catheters prior to | | | removal from the aortic arch | | | through the radial sheath. | +===================================+===================================+ | Radial loop | a hydrophilic guide wire or | | | angioplasty wire before | | | straightening with a catheter. | +-----------------------------------+-----------------------------------+ | Tortuosity in proximal vessels | also may be negotiated as above; | | | manoeuvres such as breath holds | | | and gentle ipsilateral arm | | | traction may help. | +-----------------------------------+-----------------------------------+ | Recurrent radial artery | Contrast injection may provide a | | | useful roadmap. | +-----------------------------------+-----------------------------------+ | Difficulty accessing ascending | breath holding may help to | | aorta | straighten the access route. | +-----------------------------------+-----------------------------------+ | Access bleeding & haematomas | The incidence of haematoma | | | formation is related to the | | | following factors: | | | | | | length of time the sheath is left | | | in place | | | | | | gauge (size) of the sheath | | | | | | anticoagulation | | | | | | risk factors, e.g. hypertension, | | | obesity, and pre-existing | | | peripheral vascular disease | | | | | | technique of sheath removal. | | | | | | Features that suggest a haematoma | | | may require further investigation | | | are an overlying bruit, expansile | | | mass, and a large tense swelling. | | | | | | Compression bands used post | | | radial access sheath removal. | | | | | | Femoral clamps (FemoStop®, RADI | | | Medical Systems) can be used to | | | reduce bleeding complications in | | | patients. | | | | | | Correct removal of femoral | | | sheaths by trained members of | | | staff. | | | | | | After diagnostic coronary | | | angiography, when no or little | | | heparin is given, the sheath may | | | be removed immediately. Direct | | | pressure should be applied just | | | proximal to the site of the skin | | | puncture for 5 to 10 minutes. | | | After angioplasty, it is routine | | | to wait for between 4 to 6 hours, | | | an activated clotting time | | | (ACT)\ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - +-----------------------------------+-----------------------------------+ | ECG | - - - | +===================================+===================================+ | CXR | - - | +-----------------------------------+-----------------------------------+ | Echo | - - - - - - - - | +-----------------------------------+-----------------------------------+ | Radionuclide angiography | - | +-----------------------------------+-----------------------------------+ | MRI | - | +-----------------------------------+-----------------------------------+ | Exercise Stress Testing | - | +-----------------------------------+-----------------------------------+ | Cardiac Catheterisation | - - | +-----------------------------------+-----------------------------------+ - - - - - - - - - Patients with AR are considered to be at low risk of developing endocarditis, and prophylactic antibiotics are not required before bacteraemia-causing procedures - -  - - ### Manage a patient with aortic stenosis - Calcification and fibrosis of normal trileaflet valve Risk factors for aortic sclerosis: smoking, hypertension lDL-cholesterol, elevated CRP, elevated lipoprotein a. Congenital bicuspid (increased risk with coarctation of aorta and Turner) Rheumatic Connective tissue diseases Radiotherapy Hyperlipoproteinemia syndromes CKD with abnormal calcium homeostasis - Long-standing pressure overload leads to the development of left ventricular hypertrophy (LVH). This adaptive response permits the ventricle to maintain a normal wall stress (afterload) despite the pressure overload produced by stenosis. As the stenosis worsens, the adaptive mechanism fails and left ventricular wall stress increases. Systolic function declines as wall stress increases, with resultant systolic heart failure. LVH is a contributing factor to many of the symptoms seen in AS. The consequence of concentric LVH is a smaller, less compliant chamber. Thus, left ventricle end-diastolic pressure is increased, especially during periods of increased cardiac output (e.g., exercise), leading to the sensation of dyspnoea and eventually diastolic heart failure, which typically precedes systolic dysfunction. Furthermore, in LVH, myocardial oxygen demand is greater due to increased left ventricular mass, while coronary blood flow may be reduced through a variety of mechanisms. Thus, even patients who lack coronary atherosclerotic disease may develop symptoms of anginal chest pain. - The valvular endocardium is damaged as the result of abnormal blood flow across the valve (in the case of a bicuspid valve) or by an unknown trigger (as may be the case for tricuspid valves). Endocardial injury initiates an inflammatory process similar to atherosclerosis and ultimately leads to leaflet fibrosis and deposition of calcium on the valve. Fibrosis and calcification occur slowly and are subclinical until the disease is fairly advanced. Progressive fibrosis and calcium deposition limit aortic leaflet mobility and eventually produce stenosis. Unicuspid and bicuspid valves experience abnormal shear and mechanical stresses from birth. Therefore, the pathological processes and resultant stenosis occur earlier than in trileaflet valves. In rheumatic disease, an autoimmune inflammatory reaction is triggered by prior *Streptococcus* infection that targets the valvular endothelium, leading to inflammation and eventually calcification. - +-----------------------------------+-----------------------------------+ | Exertional SoB | Ejection systolic murmur 3/6\< | | | radiated to carotid | | Fatigue | | | | - - | | Chest pain | | | | S2 diminished and single | | Exertional syncope | | | | - - | | Uncommon | | | | (Uncommon) | | Bleeding | | | | carotid parvus et tardus | | - | | | | - - | | \- Patients may describe | | | epistaxis or bruising. They are | Paradoxically split S2 | | also more likely to develop | | | chronic gastrointestinal bleeding | - - | | that is associated with | | | angiodysplasia | Gallvardin's phenomenon | | | | | | - | +-----------------------------------+-----------------------------------+ - v Natural history of aortic stenosis. A Natural course of aortic stenosis in the original (1968) description based largely on patients with rheumatic and bicuspid aortic valve disease. The onset of symptoms correlates with the sharp inflection point on the survival curve. B Natural history of aortic stenosis based on contemporary population with predominantly calcific (senile) AS and later symptom onset Prognosis - - -  Echo Peak Aortic Jet Velocity Peak aortic jet velocity increases with narrowing of the aortic valve and is a robust measure of AS severity. Particular attention must be paid to align the Doppler beam with the AS jet correctly, as errors may lead to a substantial underestimation of true aortic velocity and thus AS severity. Using a standardised approach, multiple acoustic windows should be obtained to identify the highest transvalvular velocity. Caution is warranted not to confuse the AS signal with an eccentric mitral regurgitation or even tricuspid regurgitation jet. Furthermore, in patients with subvalvular obstruction (e.g., hypertrophic cardiomyopathy), differentiation between left ventricular (LV) outflow obstruction and AS may be challenging. Continuous wave Doppler (e.g., a late-peak, dagger-shaped signal in hypertrophic obstructive cardiomyopathy) and colour Doppler are usually helpful in this setting \[3\]. As a major limitation, peak aortic jet velocity is highly flow-dependent. This might lead to a profound overestimation of AS severity in case of a high-flow state (e.g., concomitant aortic regurgitation, severe anaemia or thyrotoxicosis) and an underestimation of AVA in patients with low-flow pathology \[4\]. As a consequence, transthoracic echocardiography (TTE) examination should be repeated after correction of high-/low-flow states. If flow cannot be normalised, evaluation of AS is highly reliant on an integrated approach using additional clinical and imaging parameters. Mean Transaortic Pressure Gradient Using the simplified Bernoulli equation, transaortic pressure gradients are derived from aortic jet velocity. Due to the squared relationship between velocity and pressure gradient, any error in aortic jet velocity will inevitably result in an even greater error of the mean transaortic pressure gradient. In this context, it is important to understand that in theory an AVA of 1.0 cm² corresponds to a mean transaortic pressure gradient of 30-35 mmHg, which reflects some degree of discrepancy in the current guidelines \[5\]. In addition, mean transaortic pressure gradients might be overestimated in patients with a small ascending aorta (\ - For patients with mild or moderate stenosis, the aortic valve area decreases on average by 0.1 cm²/year and the mean gradient increases by 7 mmHg annually. It is recommended that patients with moderate AS have an echocardiogram every 1 to 2 years, and those with mild AS have one every 3 to 5 years. It is important to note that the rate of progression is extremely variable and so the recommended follow-up periods may vary between individuals. Those with severe aortic stenosis should be followed up every 6 months (at least) to allow earliest symptom detection (using exercise testing if symptoms are doubtful) and any change in echocardiographic parameters (particularly LVEF). - Antibiotic prophylaxis should be considered for high-risk procedures in patients with prosthetic valves, including transcatheter valves, or with repairs using prosthetic material, and in patients with previous episode(s) of infective endocarditis. - Indications for aortic valve replacement (surgical or transcatheter) are as follows: 1. 2. 3. 4. 5. 6. TAVR is approved for the following: 1. 2.  - +-----------------+-----------------+-----------------+-----------------+ | | Indications | Benefits | Risks | +=================+=================+=================+=================+ | Conservative | No medical | | High mortality | | | therapies | | rates | | | influence the | | | | | natural history | | | | | of aortic | | | | | stenosis | | | | | Patients with | | | | | heart | | | | | | | | | | failure who are | | | | | unsuitable (or | | | | | waiting) for | | | | | SAVR or TAVI | | | | | should be | | | | | medically | | | | | treated | | | | | according to | | | | | ESC heart | | | | | failure | | | | | Guidelines. | | | +-----------------+-----------------+-----------------+-----------------+ | Interventional | TAVI is | | Cardiac | | | recommended in | | tamponade, | | | older patients | | permanent | | | (\\_75 years), | | pacemaker | | | or in those who | | implantation, | | | are high risk | | major vascular | | | (STS-PROM/EuroS | | damage, and | | | CORE | | moderate-to-sev | | | IIf \8%) or | | ere | | | unsuitable for | | paravalvular | | | surgery. | | regurgitation | | | | | were | | | Balloon aortic | | significantly | | | valvotomy may | | more frequent | | | be considered | | after TAVI | | | as a bridge to | | compared with | | | SAVR or TAVI in | | SAVR | | | hemodynamically | | | | | unstable | | | | | patients and | | | | | (if feasible) | | | | | in those with | | | | | severe aortic | | | | | stenosis who | | | | | require urgent | | | | | high- | | | | | | | | | | risk NCS | | | +-----------------+-----------------+-----------------+-----------------+ | Surgical | SAVR is | At 3 years, | SAVR was | | | recommended in | survival was | associated with | | | younger | 83.4% after | higher risk of | | | patients who | SAVR and 72.0% | cardiogenic | | | are low risk | after TAVI | shock, severe | | | for surgery | (P=0.0015), | bleeding, and | | | (\