Diagnosis of aortic stenosis

Indications for consultations of other specialists

In the presence of indications for surgical treatment, a consultation of a cardiosurgeon is recommended.

Physical diagnostics of aortic stenosis

A presumptive diagnosis of severe aortic stenosis can be made on the basis of:

• systolic ejection noise;
• slowing and decreasing heart rate on carotid arteries;
• diffuse apical impulse;
• a decrease in the intensity of the aortic component in the formation of the II tone of the heart with its possible paradoxical cleavage.

Auscultation

Systolic noise in aortic stenosis is rough, appears shortly after I tone, increases in intensity and reaches a peak towards the middle of the period of exile, after which it gradually decreases and disappears before the closure of the aortic valve. Noise is best heard on the basis of the heart, it is well carried on the vessels of the neck. In CAS, in contrast to rheumatic and bicuspid aortic stenosis, an increase in the severity of the defect is accompanied by the following changes in systolic noise:

• a decrease in its intensity;
• change the timbre from coarse to soft;
• displacement of the auscultative maximum on the apex of the heart (symptom of Galaverden).

[1], [2], [3], [4], [5], [6], [7], [8]

Electrocardiography with aortic stenosis

The main electrocardiographic indices of aortic stenosis are signs of myocardial hypertrophy of the left ventricle, and at the same time their absence does not exclude the presence of even a critical aortic stenosis, especially in the elderly. Often there is an inversion of wave E and depression of the ST segment in leads with a cortical position of the ventricular complex. Often, depression of the ST segment is more than 0.2 mV, which is an indirect sign of concomitant hypertrophy of the left ventricle. Occasionally, it may be noted "infarct-like" ECG changes, consisting in a decrease in the amplitude of the R wave in the right thoracic leads.

Atrial fibrillation in patients with non-critical aortic stenosis is evidence of mitral valve involvement. The spreading of calcifications from the aortic valve to the conduction system of the heart leads to the appearance of various variants of atrioventricular and intraventricular blockades, usually determined in patients with concomitant calcification of the mitral valve,

[9], [10], [11], [12], [13], [14], [15], [16], [17],

Radiography of chest organs

Usually, the aortic calcification is diagnosed and the poststenotopic dilatation of the aorta is diagnosed. In the later stages, dilatation of the left ventricular cavity and signs of stagnation in the lungs are noted. With the concomitant defeat of the mitral valve, the expansion of the left atrium is determined.

Echocardiography

Recommended for patients with aortic stenosis for the following purposes (class I).

• Diagnosis and assessment of the severity of aortic stenosis (level of evidence B).
• Evaluation of the severity of left ventricular hypertrophy, chamber size and left ventricular function (level of evidence B).
• Dynamic examination of patients with established aortic stenosis with a change in the severity of clinical signs or symptoms (level of evidence B).
• Assessment of the severity of the defect and left ventricular function in patients with established aortic stenosis in pregnancy (level of evidence B).
• Dynamic observation of asymptomatic patients; annually with severe aortic stenosis; every 1-2 years with mild to moderate and every 3-5 years with mild aortic stenosis (level of evidence B).

The severity of aortic stenosis is assessed according to the following criteria.

The severity of aortic stenosis according to the 2dEhoKG study

Index;		Power
	I	II	III
Area of the aortic orifice, cm 2	> 1.5	1.0-1.5	<1.0
The average pressure gradient on the aortic valve (norm <10), mmHg.	<25	25-40	> 40
The maximum blood flow rate on the aootaltic valve (1.0-1.7 norm). M / s	<3.0	3.0-4.0	> 4.0
Valve hole index, cm 2 / m 2	-	-	<.0,6

In some cases, there are significant difficulties in differential diagnosis between rheumatic and calcified aortic stenoses, additional signs of which are indicated in the table.

[18], [19], [20], [21], [22], [23], [24], [25]

Comparative characteristics of rheumatic and calcified aortic stenosis

Symptoms	Calcified aortapic stenosis	Rheumatic aortic stenosis
Age	20-50 years old	Older than 60 years
Floor	Mostly male	Mainly female
Anamnesis	A history of LRA	Lack of a history of ORL
Dynamics of the symptoms of the disease	The gradual development of Roberts's triad (angina pectoris, syncopal conditions, dyspnea)	The aborted character of the symptoms, the debut of the disease with the appearance of signs of CHF (76-85%)
Features of systolic noise	Noise of a rough character, with localization above the aorta and carrying on the vessels of the neck	The noise is of a soft, often musical nature ("gull yelling") over the aorta with a predominant conduct to the apex of the heart, where it often reaches a maximum (symptom Gailave-din)
II Tone	Weakened	Normal or reinforced
IV tone	Rarely	Often
Changes in aortic valve flaps	Boundary fusion, calcification. Immobilization of valves with subsequent calcification of the fibrous aortic valve ring	Expansion, calcification of the fibrous ring, followed by a decrease in the area of the opening and the spread of calcification to the valves. Sealing and thickening of valves (aortic sclerosis) with long-lasting mobility
Posthenstenotic enlargement of the aorta	Extremely rare (<10%)	Often (45-50%)
The defeat of other valves	Often	Rarely
Concomitant diseases (arterial hypertension, ischemic heart disease)	Rarely (<20%)	Often (> 50%)

[26], [27], [28], [29], [30], [31], [32]

Load tests for aortic stenosis

Can be performed in asymptomatic patients with aortic stenosis to determine the symptoms or pathological changes in BP (decrease or increase of less than 20 mm Hg systolic BP), provoked by physical exertion (level of evidence B). Load tests are not indicated if there are symptoms of aortic stenosis (level of evidence B).

Coronary angiography

It is indicated to patients with aortic stenosis for the purpose of verification of concomitant IHD, as well as before aortic valve replacement (AUC) to determine the extent of surgical intervention.

[33], [34], [35]