Nov 19, 2020 in Case Studies

Aortic Stenosis in the Elder Adult
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Case Analysis Pathophysiology of Aortic Stenosis in the Elder Adult

Pathophysiology

Aortic stenosis refers to a reduction of aortic valve opening, resulting to a restricted blood flow. Movement of blood in the body becomes more problematic. The condition initiates with an aortic sclerosis before extending to aortic stenosis that is marked with severe leaflets calcification. Sometimes leaflets stiffen and become too rigid for the normal opening during systole. In such a case, there appears the risk of heart failure because stiffen leaflets may cause cardiac stress. Nearly 7% of the world populations above 65 years old are prevalent to this condition (McCance & Huether, 2014). It affects millions of people, and it is considered as a public health concern in the United States. The disease affects men more than women with more than 80% of the affected people being males. Survival rates are 50% for people aged 65 years. However, upon replacement of the aortic valve, the survival rate increases. Lack of replacements reduces the rate to 20% after five years.

Aortic valve disease affects the extracellular matrix and alters its composition, organization, and mechanical properties. Changes in the cellular and molecular properties interfere with heart functioning. The extent of extracellular matrix determines the extent of the ailment and suggests the most appropriate treatment process. Patients are likely to experience pulsus alternans, prominent S4, systolic murmur, ejection click, hyperdynamic, accentuated P2, and absent or diminished A2. In addition, paradoxical S2 splitting is also possible.

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Image showing stiff aortic valve opening image1.png

Images comparing healthy and diseased aortic valves

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Mild to severe symptoms may be realized, depending on the extent of narrowing effect on the valves. Symptoms become more pronounced as the condition worsens. Some of the symptoms include angina, rapid or irregular heartbeat, breath shortness, fatigue, swollen feet and ankles, and palpitations. Other symptoms include difficulty when exercising, dizziness, fainting, and lightheadedness. Increased activities lead to fatigue, and the patients feel tired quickly. Shortness of breath increases during exertion. Palpitations can also be realized and create uncomfortable feelings. However, heart valve ailment can occur in the absence of any outward symptoms. They experience debilitate symptoms that hinder their mobility and ability to be involved with beneficial daily activities (Osnabrugge et al., 2013). For instance, patients find it difficult to walk over long distances or when climbing stairs. Advancement of the aortic valve results to the realization of two sequelae. These are left-sided heart failure and fixed cardiac output that cannot increase during exertion. The problem results to build-up of pressure in the left ventricle with concentric hypertrophy. The increasing pressure on the left ventricular raises the demand for myocardial oxygen, resulting to an increase in the stress on the left ventricular wall and mass. The high pressure on the left is usually diverted back into the left atrium (Moat et al., 2011). Congestion in the pulmonary circulation is realized when the left atrium fails to empty itself. Increased pressure on the left can contribute to heart failures on the right and to an eventual collapse.

Diagnosing Aortic Stenosis

In most cases, the condition is diagnosed during a routine heart and asymptomatic examination. Certain features and characteristics, particularly in the peripheral pulse, can offer conditions indication. A sustained or slow upstroke of the generated pulse from the artery, accompanied by a reduced volume is an indication of this condition. Delays on auscultation and the carotid artery pulse referred to as the apical-carotid delay is another clear indication. Patients may have an ejection click from the apex and the lower left sterna border. Auscultation is one of the methods of estimating and detecting diseases severity. Delayed carotid upstroke, audible systolic heart murmur, and absent or soft second heart sound are the diseases indicators (Moat et al., 2011). In severe stenosis, longer duration marked with consistent peak is realized. However, stenosis severity is not always indicated with the murmur loudness.

 
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Multiple modalities can be applied to diagnose severe stenosis. They include auscultation, chest X-ray, Cardiac catheterization, Transthoracis Echo (TTE), and Electrocardiogram. Transthoracis Echo (TTE) offers gold standard guidelines to support diagnosis of severe aortic stenosis. Chest X-ray indicates the diseases severity through showing the size of the left ventricle, and atrium and valve calcification degree. Echocardiogram offers an effective non-invasive test to determine the functioning of the aortic valve and its anatomy (McCance & Huether, 2014). Heart catheterization indicates the severity in valve areas and offers a definite diagnosis. Electrocardiogram facilitates identification of various electrocardiographic abnormalities that can be related to Aortic Stenosis.

Treatment

Treatment is not necessary for patients without symptoms. However, as symptoms advance to moderate, echocardiography should be performed to reveal the progress. In some cases, it can be supported with a cardiac stress test. Patients may be treated for heart failure symptoms, as well as abnormal heart rhythms, including atrial fibrillation. Some of the medicines applied include nitrates, beta-blockers, and diuretics. Although high blood pressure can be treated, physicians must be careful to prevent excessive pressure reduction. Patients with mild symptoms are prescribed to medications meant to prevent blood clots, regulate heart functions, and reduce symptoms.

Severe aortic stenosis can only be treated through replacement of the affected aortic valve. Replacement must be done when the effect of the condition becomes a threat to the patient. There are two methods of replacing diseased aortic valves, namely Transcatheter Aortic Valve Replacement (TAVR) and Surgical Aortic Valve Replacement (AVR). Transcatheter Aortic Valve Replacement is usually applied to patients with increased risk, associated with the traditional surgery procedures. It involves inserting a new valve within the affected aortic valve. On the other hand, AVR is the common replacement procedure and involves removal and replacement with a biological or a mechanized valve. Biological valves are developed from human or animal tissues. Minimal-incision valve surgery (MIVS) can also be used to replace the aortic valve. It involves a small incision, and is done to patients with minimal surgery risk.

Image Showing Surgical aortic valve replacement

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Image Showing Transcatheter aortic valve replacement

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Patients are advised to keep away from strenuous activities even when there are no symptoms. They must avoid unhealthy and risky practices, such as smoking and alcoholism. Patients must regularly exercise and maintain a healthy weight. It is beneficial to seek advice from health experts on the most appropriate exercises, depending on patients age and severity of condition (Osnabrugge et al., 2013). The process can be supported by the development of a weight loss plan to avoid excessive fat accumulation. Patients must ensure healthy eating habits, including vegetables, low-fat dairy products, fruits, whole-grain breads, and fish. It is beneficial to avoid fast and fatty foods that pose a risk to their health. They should sleep with their feet and head elevated.

In addition, patients must ensure completion and timely administration of the prescribed medication (Moat et al., 2011). They must also observe changes in their body and seek medical attention as soon as possible. It is important to seek medical support, in case a patient experiences bleeding gums and nose, fever, blood in the bowel or urine, fast heartbeat, breath shortness, and prolonged chest pains. Patients should learn how to measure their pulse to facilitate immediate detection of complications. Patients with high blood pressure must adhere to their medication and check their condition every day.

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