Aortic stenosis (AS)

The aortic valve sits between the left ventricle (main chamber) of the heart, and aorta (the main blood vessel leaving the heart to carry oxygenated blood around the body). Over time the ‘leafs’ of the valve can thicken and become less flexible (stenosed), reducing its ability to open and close. This means less blood flows through it when open, and blood leaks out when it should be closed (causing a murmur that can be heard with a stethoscope). This affects the pressure the heart can generate to pump blood, reducing the effectiveness of each beat.

Similar to ACS, a stenosed aortic valve (AS) reduces blood flow from the heart to the bodies tissues. The effects of AS are more pronounced when the demand for blood increases on exertion. When severe this can cause chest pain and syncope (fainting) on exertion. An ‘ejection systolic murmur’ can be heard with a stethoscope from the top right sternal edge (location of the valve) radiating to the right carotid in the neck (the direction of blood flow).



Pericarditis

This is inflammation of the pericardium, a fibrous bag around the heart. It can follow a viral infection, heart attack, or heart surgery, but the cause is often unknown. Pericarditis causes a sharp, stabbing, knife-like pain, which may be made worse on deep breathing or by lying down. The pain may be relieved by leaning forwards. A pericardial friction rub may be heard on auscultation.



Aortic aneurysm and dissection

The blood is at its highest pressure in the aorta, the biggest artery it is pumped through after leaving the heart. A tear in the inner wall is called an aortic dissection. It usually happens because the wall has been weakened over time by uncontrolled high blood pressure, trauma, or a genetic condition which affects its structural integrity. A sudden dissection can kill, and fast. The chest pain occurs suddenly and is often described as tearing, ripping, or shearing. It may radiate up to the neck, through to the back, and down to the stomach. On examination, a patient may have unequal radial pulses at the wrist if the tear occurs between the branches off the aorta to each arm (the branch after the tear is weaker).

Although complete rupture can occur (which allows blood to leak into the chest cavity), it is more common that blood peels apart the layers of the aorta wall and collects here in a ‘false lumen’ (the ‘true’ lumen being the channel blood usually travels). This ballooning of the false lumen is called an aortic aneurysm. Aneurysms cause all sorts of problems:

Haemodynamic instability: with blood leaking from an important high pressure system, the heart may not be able to compensate for lost volume and pump enough blood to the other tissues. Extension: aneurysms can extend right along the aorta from the chest to the pelvis. This can occur at the time of the initial dissection, or progress over time if not managed. Extension causes particular problems at branching points of the vessel, where the blood supply to the branch can be compromised, or rely on the false lumen (which complicates surgery). Mass effect: the size of the aneurysm can compress tissues around it such as other blood vessels, the heart and lungs, digestive tract, etc. Rupture & death: the wall of an aneurysm is stretched and weaker than a healthy vessel. It is sometimes thought of as a ‘ticking time bomb’ as it can burst. However, this risk is proportional to the size of aneurysm so surgeons often recommend monitoring until the ‘risk of rupture’ outweighs the risk of major surgery to repair.

Respiratory

Pulmonary embolism (PE)

Clots that form in veins often get stuck in the artery leaving the heart and branching into the lungs (pulmonary artery). Until this point, the size of the veins and heart chambers it has travelled through will have been increasing, but the path suddenly narrows as vessels branch into the lungs. A clot here can be catastrophic as it cuts off circulation to all or part of one or both lungs (depending on the size and how far it travels before sticking). Reduced blood flow through the lung tissue makes that tissue less effective at breathing, a bit like suffocating from the inside. People can feel pleuritic chest pain (worse on deep breaths), breathless, and have worse symptoms on exertion. A deep vein thrombosis (DVT) is sometimes the herald of a PE, we take leg clots so seriously to prevent them breaking off to become the more life-threatening PE.