Management of Aortic Stenosis
Four categories of severity:
1) Valve area > 1.2 cm2 – mild
2) Valve area 1.0-1.2 cm2 - moderate
3) Valve area 0.8-1.0 cm2 - severe
4) alve area < o.8 cm2 - critical

Surgical treatment,
For symptomatic ptnts- w/out valve replacement:
- 50% presenting with angina will die within five years,
- 50% presenting with syncope will die within three years
- 50% presenting with dyspnoea will be dead within two years

- Aortic valve replacement (AVR)- for most adult with calcific AS and severe obstruction
- Indicated in patients with severe AS who are symptomatic and those who exhibit LV dysfunction
- Surgery on patients with severe AS who are asymptomatic with normal LV function should be postponed since they may continue to do well for many years – risk of surgical mortality exceeds that of sudden death in asymptomatic patients

Aortic Valve replacement
- Mechanical vs bioprosthetic valve
1) Bioprosthetic valve- doesn’t require long-term oral anticoagulation but has relatively limited durability
2) Mechanical valve- offers long- term durability but requires lifelong warfarin therapy- can develop significant hemorrhagic complications

- Palliative, not curative
- Commits a patient to continued IE prophylaxis, regular cardiac follow-up and continued med therapy (inc anticoagulation with warfarin-those with mechanical valves)
- Re-operation- malfunction of the prosthetic valve.
- some patients may require implantation of a permanent pacemaker after valve surgery.

Percutaneous balloon aortic valvuloplasty
- preferable in children and young adults with congenital, noncalcific AS
- not commonly used in adult with severe calcific AS – because of ↑ restenosis rate


Asymptomatic patients with mild to moderate AS
- Should be on under regular review for assessment of symptoms eg changes in exercise tolerance and echocardiography
- Should avoid strenuous act, and post-prandial exertion
- a/biotic prophylaxis against IE is important
- HPT occurs in about 20%-30% of patients
1) Managed with ACE inhibitors or ARB titrated slowly
2) Beta-blockers are also used in selected ptnts


Management of HPT

Lifestyle
- Stop smoking
- Weight ↓ if necessary- maintain ideal BMI of 18-23
- ↓salt intake, total fat, saturated fat and cholesterol intake
- ↑ polyunsaturated, monosaturated fats
- ↑ fruit, vege, whole grains, fish
- Cut alcohol intake
- Regular exercise
- Relaxation therapy can help

Antihypertensive drugs

Main agents used:
1)Thiazide diuretics
- Actions:
i.↑ salt and H2O excretion-->↓ ECF vol
ii.↓ cardiac output through ↓ plasma vol

2)Beta-blockers
-Actions:
i.↓ CO
ii.↓sympathetic act-->↓vasoconstriction-->↓peripheral resistance
iii.↓renin release-->↓ATI and II-->↓vasoconstriction

3)Calcium channel blockers
-Action:
i.Block Ca entry through Ca channels-->vasodilation-->↓arterial p

4)ACE inhibitors
-Actions:
i.Inhibit ACE-->ATI not converted to AT II-->↓vasoconstriction