ANSWERS WILL BE POSTED on 1st February at 18:00 CET

A 78-year old gentleman came into A&E short of breath and complaining of chest pain that came on suddenly over a few minutes.

1. What are the common causes of chest pain ? Please be systematic when writing your differential diagnosis.

When auscultating, you note an ejection-systolic murmur heard over the left sternal edge and the aortic area. This radiated to his carotids.

2. What would be the two possible diagnosis ? Which one of these is most likely ?

You order all the necessary blood tests including a full blood count. As well as, the serum levels of troponin and CK-MB (Creatinine Kinase and Myocardium B fraction).

3. How would you further investigate this patient ? Describe the typical findings found, keeping in mind the most likely diagnosis mentioned in 2.



4. Would you suggest exercise testing in this patient ?

5. How would you manage this patient ?

6. Comment on the overall prognosis.

Source: https://academic.oup.com/eurheartj/article/26/24/2714/2888049/Decision-making-in-elderly-patients-with-severe

http://emedicine.medscape.com/article/347673-overview

ANSWERS

1.

2. Aortic Stenosis (most likely) and Hypertrophic cardiomyopathy

3. Typical Findings of Aortic Stenosis

ECG: P-mitrale. Left ventricular hypertophy with strain pattern and poor R-wave progression. Left Bundle Branch block or complete Atrioventricular block if calcified ring is present.

Chest X-ray: Left ventricular hypertrophy and a calcified aortic valve are visible. As well as, post-stenotic dilatation of the ascending aorta.

Echocardiogram: Preferred diagnostic modality showing calcified aortic valve.

Doppler Echo: To estimate the gradient across the valves and quantifying the degree of stenosis.

Cardiac catheter: To assess valve gradient, left ventricular function and coronary artery disease.

4. No, symptomatic Aortic Stenosis is an absolute contraindication for exercise testing.

5. Medical Therapy

In general, pharmacological therapy is not effective in treating aortic stenosis. However, it can be useful to treat existing comorbid conditions.

Angina–> Beta blockers or calcium channel blockers. Nitrates are contraindicated due to risk of hypotension.

Heart Failure–> Digoxin and ACE-Inhibitors

Hypertension is treated aggressively.

Surgery

In symptomatic adults, aortic valve replacement is routinely done with mechanical or a tissue prosthetic valve. This usually improves the long-term prognosis in patients fit for surgery.

If the patient is not fit for surgery, percutaneous valvuloplasty or replacement (transcatheter aortic valve implantation) can be done.

6. If left untreated, severe symptomatic aortic stenosis carries a poor prognosis with 55% of patients carrying a 2-year mortality rate.

Prognosis after replacing the aortic valve for patients above 65 years of age, is roughly the same as that of the general population.