Data is based on ESC & ACC guidelines 2017
Assessment of aortic stenosis severity
Step by step management algorithm
Management in special populations
Case-based questions
MCQs
Most common type of birth defect
Defect in structure or function of the heart and great vessels
1 in 1000 live births
The incidence is higher in stillborns (3-4%), spontaneous abortuses (10-25%), and premature infants
About 1 in 4 babies born with a heart defect has a critical heart disease
Digital Health Market has exploded in the last few years. Will that continue? What are the main areas of growth in digital days and what the future will bring us.
ANA testing is confusion and many times getting a positive ANA complicates the clinical picture. A few tips to know what to do when you have a positive ANA.
Living with rheumatoid arthritis is challenging. Besides the benefit of getting shortly on medication after diagnosis, lifestyle modifications play an important role in rheumatoid arthritis management. Diet, exercise, sleep, medication can be very helpful.
Telemedicine in rheumatology can help the shortage of physicians across US. Covid-19 crisis showed us that telemedicine in rheumatology is highly effective, cost efficient, convenient and can provide excellent care for patients in a safe environment without the unnecessary exposure to coronavirus.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
2. CC: chest pain
HPI:
• 64 yo WM admitted for chest pain that
started about 2 years ago; became
progressively worse, initially appeared with
walking aprox 1 mile and progress to less
then 1 block.
• CP described as pressure in his mid-
chest, always with exertion, nonirradiating,
rated as 6-7/10, attenuated by rest,
accompanied by DOE.
• Denies palpitations or syncopal episodes.
3. ROS
• No fevers, chills, or weight loss.
• Skin: Skin, hair, nail changes. No rash or pruritus
• Neurologic: No syncope, weakness, seizure ,
headaches/ gait abnormalities.
• Eyes: No blurred vision
• ENT: No hearing loss. No epistaxis, nasal discharge.No
bleeding gums, or sore throat
• CV: ++ CP,+ SOB, No palpitations/no claudication.
• Respiratory: + SOB, no wheezing, +dry cough, denies
asthma, COPD or chronic bronchitis
• GI: No change in appetite, dysphagia, nausea, vomiting,
constipation, diarrhea
• Psychiatric:+anxiety. No memory loss or AMS
4. PMHx
• CAD (coronary artery disease)
• Hypertension
• Hyperlipidemia
• Diabetes mellitus type II
• Depression with anxiety attacks
• Obesity
6. Home medication
• insulin (HUMULIN 70/30) and Insulin Detemir
• lorazepam 0.5 mg PO tablet
• NORTRIPTYLINE 30 mg PO
• CHOLECALCIFEROL, VITAMIN D3, PO
• amlodipine-benazepril 10-40mg PO
• aspirin 81 mg PO
• Clopidogrel 300 mg PO
• Esomeprazole 20 mg PO
• irbesartan-hydrochlorothiazide (AVALIDE) 150-
12.5 mg PO BID
• Nebivolol 10 mg PO Tab
• simvastatin (ZOCOR) 40 mg PO.
7. Vital signs
• BP 146/58
• Pulse 82
• Temp 98.6 °F (37 °C) (Oral)
• Resp 20
• Ht 6' 2" (1.88 m)
• Wt 285 lb 9.6 oz (129.547 kg)
• BMI 36.67 kg/m2
• SpO2 97%
8. Physical examination
• Constitutional: NAD
• HEENT: NC/AT, EOMI, PERLA, normal bilateral external
ears, oropharynx and nose
• Neck: Normal ROM, No JVD, carotid upstrokes are
preserved without audible bruits.
• Cardiovascular: RRR, S1&S2 normal. 2/6 Systolic
crescendo-decrescendo murmur present in right 2nd ic
area, no galops or rub.
• Lungs: CTA, bilateral crackles in the bases
• GI: Soft, NT, BS normal, No pulsatile masses.
• Extremities: Intact distal pulses, No edema
• Neurologic: AO x 3, Normal motor and sensory function,
No focal deficits.
• Skin: Warm, Dry, No erythema, No rash.
• Psychiatric: Normal affect and mood
11. CXR
• Stable cardiomegaly.
• Mediastinal contours unremarkable.
• No pulmonary infiltrate or pleural
effusion.
• Pulmonary vessels within normal
limits.
IMPRESSION:
No acute disease
12. ECHO
• LV: The cavity size was normal. There was mild
concentric hypertrophy. Systolic function was normal.
The estimated EF: 50% to 55%. Severe hypokinesis of
the mid-distalanteroseptal myocardium. Mild
hypokinesis of the lateral myocardium.
• abnormal LV (grade 1 DD).
• Aortic valve: Moderate focal thickening and calcification.
Cusp separation was markedly reduced. There was
severe stenosis. Mean gradient: 32mm Hg (S). Peak
gradient: 68mm Hg (S). Valve area: 0.88cm^2(VTI).
Valve area: 0.83cm^2(Vmax). Aorta: Aortic root
dimension: 50mm (ED, M-mode).The aortic root was
dilated.
• LA: The atrium was moderately dilated.
13. Previous heart investigations
• 2008: Heart cath- CAD -inf isch, 70% m
LAD, 70%ndom RCA.
• 2010: Lexi scan that revealed EF 60%,
normal coronary perfusion.
• 2009 Carotid duplex: 20 - 49% Right ICA,
< 20% Left ICA, Vertebral: Bilateral
Antegrade Flow
14. Heart catheterization during this admission
Right and Left Heart
Catheterization and
Hemodynamics
Right atrium 13/13/11
Right ventricle 51/9
Pulmonary artery 40/22/31
Pulmonary artery wedge 21/24/19
Left ventricle 157/34
Aorta 106/59/79
16. Left ventriculography
Estimated EF
Wall motion
30%
Anteroapical hypo-akinesis and inferoapical
dyskinesis
Valve function No definite MR is seen.
Coronary
angiography
Dominance left
Left Main normal
LAD Courses to the undersurface of the apex and gives rise to
a large diagonal branch. There is 90%focal early mid
LAD stenosis.
Left Circumflex Supplies 2 obtuse marginal branches and posterior artery
branch and the PDA. There is diffuse 80% stenosis at the
distal end of the first obtuse marginal branch there is
50% focal proximal stenosis of the LPDA
Right There is hazy 70% ostial stenosis and 70% mid stenosis
of the nondominant RCA
22. Etiology of valvular AS
• Congenitally abnormal valve
with superimposed calcification
(uni/ bicuspid)
• Calcific disease of a trileaflet
valve
• Rheumatic valve disease
• Rare causes include metabolic
diseases (Fabry's disease),
SLE, Paget disease, CKD
23. Normal aortic valves
effective area of valve opening =
cross-sectional area of LV tract
(3.0 to 4.0 cm2 )
Normal Bicuspid valve Geriatric valve
24. Pathophysiology
• Ao valve sclerosis: no significant gradient (Ao
jet velocity ≤2.5 m/sec)
• Aortic stenosis - antegrade velocity across an
abnormal valve is at least 2.6 m/sec.
• When AS becomes hemodynamically
significant, it results in obstruction to LV and
LV adaptive changes (concentric hypertrophy);
• LVEDV are maintained for a prolonged period
despite a systolic pressure gradient between
the LV and peripheral arterial system
• Symptoms occur when valve area is <1.0 cm2,
the jet velocity is over 4.0 m/sec, and/or the
mean transvalvular gradient exceeds 40
mmHg
25. Classic symptoms
1. decreased exercise tolerance and
dyspnea on exertion (Heart failure)
2. Syncope or dizziness
3. Angina
26. Physical examination
• A slow rate of rise in the carotid pulse
• S2 is soft and single (A2 is delayed and
tends to occur simultaneously with P2)
• S2 may become paradoxically split when
the stenosis is severe and associated with
LV dysfunction
• S1 is usually normal
• Vigorous left atrial contraction can lead to
a fourth heart sound (S4).
27. Aortic Stenosis: Physical Findings
S1 S2 S1
S2
Mild-Moderate Severe
An early peaking murmur is typical for mild to moderate AS
Late peaking murmur is consistent with severe AS.
29. AS severity
Severity Mean gradient,
mm Hg
Aortic valve
area, cm2
Mild <25 >1.5
Moderate 25-40 1.0-1.5
Severe >40 <1.0
Critical >80 <0.7
30. Question 1
Which of the following parameters is NOT
helpful in determining the need for
surgery in severe chronic aortic
regurgitation (AR)?
A. Decreasing exercise tolerance
B. Left ventricular (LV) end-systolic
diameter
C. Severity of pulmonary hypertension
D. LV end-diastolic diameter
E. LV ejection fraction
31. Answer:
Answer: C. Severity of pulmonary
hypertension. Indications for AVR in
patients with severe chronic AR include
onset of symptoms, worsening exercise
tolerance, declining EF, and severe LV
dilatation. Unlike mitral valvular disorders,
pulmonary hypertension is not usually a
prominent feature of chronic AR except in
the late stages when the decompensated
ventricle leads to congestive heart failure.
32. ACC/AHA 2008 –ECHO recommendations
Class I
• diagnosis and assessment of AS severity
• assessment of LV wall thickness, size, and
function
• re-evaluation of patients with known AS
and changing symptoms or signs.
• assessment of changes in hemodynamic
severity and LV function in patients with
known AS during pregnancy.
• re-evaluation of asymptomatic patients:
every year for severe AS; every 1 to 2
years for moderate AS; every three to five
years for mild AS
• measurement of jet velocity and
calculation of the left ventricular-aortic
gradient and the valve area
• Ao regurgitation (80%)
33. Question 2
• A 75-year-old man is referred to you for evaluation of
his first syncopal episode. He does not recall any
seizure-like activity associated with the episode. He
reports no palpitations, chest pain, orthopnea, or lower
extremity edema. He has led a rather sedentary life
since his wife passed away 5 years ago. His physical
examination is significant for normal BP and HR and a
crescendo-decrescendo murmur at the right upper
sternal border radiating to the carotids. The murmur
sounds late peaking in systole, and A2 is diminished.
TTE shows LVH with preserved LV function and aortic
stenosis (AS) with an estimated aortic valve gradient
of 65 mm Hg. Which of the following tests would be
the most appropriate next step?
A. Transesophageal echocardiography (TEE)
B. Dobutamine stress echocardiography
C. Holter monitoring
D. Coronary angiography
E. Electrophysiology study
34. Answer
Answer: D Coronary angiography- This
patient needs an AVR. He should have
a preoperative cardiac catheterization
to determine the need for concomitant
CABG.
35. ACC/AHA 2008 -Cardiac catheterization
recommendation
Class I
• patients with AS at risk for CAD
• at the time of aortic valve replacement to
identify patients who might also benefit from
coronary artery bypass graft surgery
• symptomatic patients in whom noninvasive
tests are inconclusive or provide discrepant
results from clinical findings regarding the
severity of aortic stenosis
• risk of cerebral embolization associated with
crossing the Ao valve in patients with severe
calcific aortic stenosis
36. Medical Treatment
• Antibiotic prophylaxis is NOT recommended
in all pts with AS for prevention of infective
endocarditis.
• Caution with diuretics and vasodilators
(reduce preload)
• HTN should be treated cautiously with
appropriate antihypertensives (preload
dependence)
• Statins have been studied to see if they
cause regression or delayed progression of
leaflet calcification (need more data)
37. Question 3
• An 89 yo F is evaluated during a routine examination.
She maintains her exercise regimen, which includes
walking three or four times per week, but notes that she
is more easily fatigued than she used to be. It takes her
almost an hour to walk her current route, which took 25
to 30 minutes a year ago, and she occasionally has to
pause to catch her breath. She denies angina,
presyncope, syncope, or pedal edema. PMHx:
hypertension and osteoporosis. She is currently taking
hydrochlorothiazide, lisinopril, alendronate, calcium, and
a multivitamin.
38. Question 3 -continuation
• PE: temp-normal, BP- 148/90 mm Hg, HR- 82/min.
Estimated CVP is 4 cm H2O. There is a sustained apical
impulse. S1 is normal. There is a single S2 and an S4 but
no S3. A grade 3/6 late-peaking systolic murmur is heard
best at the right second intercostal space, with radiation
into the right carotid artery. Carotid artery upstrokes are
delayed. Lungs are clear.
• TTE shows concentric LVH and normal systolic function.
There is a trileaflet aortic valve with heavy calcification.
Aortic jet velocity is 4.8 m/s, peak transaortic gradient is
92 mm Hg, and valve area is 0.7 cm2.
39. Question 3- continuation
Which of the following is the best
management option?
A. Aortic balloon valvuloplasty
B. Aortic valve replacement
C.Discontinue hydrochlorothiazide and
begin furosemide
D.Clinical follow-up in 1 year
40. Answer:
• Correct answer: B- in severe, symptomatic
aortic stenosis, AVR improves long-term
survival and quality of life.
41. Effective treatments for severe AS.
1. Surgical replacement of
the aortic valve
2. Transcatheter aortic
valve replacement
(TAVR)
42. ACC/AHA 2008 Indications for Aortic Valve
Replacement (AVR)
Class I
1. symptomatic patients with severe AS.
2. patients with severe AS undergoing
CABG or surgery on the aorta or other
heart valves.
3. patients with severe AS and LV
systolic dysfunction (EF < 0.50)
43. ACC/AHA 2008-Aortic Balloon Valvotomy
Class IIb
1. reasonable as a bridge to surgery
in hemodynamically unstable adult
patients with AS who are at high
risk for AVR
2. reasonable for palliation in adult
patients with AS in whom AVR
cannot be performed because of
serious comorbidities
Class III –NOT recommended as an
alternative to AVR in adult patients
with AS; pregnancy may be an
exception
44. Transcatheter aortic valve
replacement (TAVR)
• has been developed for treatment of patients
with severe symptomatic AS
• who have an unacceptably high estimated
surgical risk
• due to technical issues with surgery (eg, a
porcelain aorta or prior mediastinal radiation,
prior pericardiectomy with dense adhesions
or prior sternal infection with complex
reconstruction, or a patent left internal
mammary graft lying beneath the sternum)
45. 2012 American College of Cardiology
Foundation/American Association for Thoracic
Surgery
Calcific aortic valve stenosis with the following
echocardiographic criteria:
1. Severely calcified valve leaflets with
reduced systolic motion AND
2. Mean gradient >40 mm Hg or jet velocity
>4.0 m/s OR
3. Aortic valve area of <1.0 cm2 or indexed
effective orifice area <0.5 cm2/m2