eMedicine Specialties > Emergency Medicine > Cardiovascular

Aortic Stenosis: Treatment & Medication

Author: Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas Hospital
Coauthor(s): Daniel P Lombardi, DO, Clinical Assistant Professor, New York College of Osteopathic Medicine; Clinical Preceptor, Albert Einstein College of Medicine of Yeshiva University; Attending Physician and Interim Program Director, Department of Emergency Medicine, Saint Barnabas Hospital
Contributor Information and Disclosures

Updated: May 29, 2009

Treatment

Emergency Department Care

  • Prehospital and ED management is focused on acute exacerbations of the symptoms of aortic stenosis (AS).
    • As always, assess and address airway, breathing, and circulation.
    • If the patient is in cardiopulmonary arrest, perform resuscitation according to the recommendations of the American Heart Association in their Advanced Cardiac Life Support guidelines.
    • A patient presenting with uncontrolled congestive heart failure (CHF) should be treated supportively with oxygen, cardiac and oximetry monitoring, intravenous access, loop diuretics, nitrates (remembering the potential nitrate sensitivity of patients with aortic stenosis), morphine (as needed and tolerated), and noninvasive or invasive ventilatory support (as indicated).
  • Diagnostic studies in the ED should include ECG, chest radiography, serum electrolyte levels, cardiac biomarkers, and a CBC. Arterial blood gas measurements are generally not necessary but may be obtained if hypoxemia or a mixed respiratory disease state is suspected. Emergency formal ultrasonography may be useful in centers that have this capability.
  • Vasodilators should be used judiciously in patients with aortic stenosis because they may cause a significant drop in blood pressure.
  • Patients with severe heart failure due to aortic stenosis that is resistant to medical management should be considered for emergent surgery.
  • A patient presenting with angina pectoris requires monitoring and studies as listed above. Measures should be taken to relieve the chest discomfort. This may include administration of nitrates, oxygen, and morphine.
  • Nitroglycerin-induced syncope occurs more often in patients with aortic stenosis than in those without aortic stenosis. This information should be obtained through the history at presentation.
  • Syncope in the face of aortic stenosis should be assessed and treated as in any patient presenting with a syncopal episode.
  • A patient with aortic stenosis may present initially with one or more of the above complaints. A thorough history and physical examination should be obtained in addition to baseline laboratory studies, chest radiography, and an ECG. Hospital admission, telemetry/intensive care unit admission, and cardiology consultation all should be considered. If available, an echocardiography may be indicated in the ED.
  • Atrial fibrillation in the setting of aortic stenosis is considered a medical emergency and should be converted urgently in patients who are hemodynamically unstable. Associated symptoms also should be treated urgently.

Consultations

  • Cardiologist
  • Cardiothoracic surgeon: The only definitive treatment for aortic stenosis is aortic valve replacement. If a patient develops symptoms due to aortic stenosis, then a clear indication for replacement exists. According to Sabiston Textbook of Surgery, angina and syncope warrant elective surgical therapy, whereas congestive heart failure mandates urgent intervention. In cases where patients who do not have any symptoms secondary to aortic stenosis then the issue of valve replacement becomes less clear. For patients who are not candidates for aortic replacement, percutaneous aortic balloon valvuloplasty may provide some symptom relief.1

More on Aortic Stenosis

Overview: Aortic Stenosis
Differential Diagnoses & Workup: Aortic Stenosis
Treatment & Medication: Aortic Stenosis
Follow-up: Aortic Stenosis
Multimedia: Aortic Stenosis
References
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References

  1. Townsend CM, et al. Sabiston Textbook of Surgery. 18th ed. Saunders; 2008:1841-1844.

  2. Ashley EA, Niebauer J. Chap 9 - Valve disease. In: Cardiology Explained. London: Remedica; 2004.

  3. Valvular emergencies. In: Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York: McGraw-Hill; 2004:54.

  4. Aortic valve disease. In: Topol EJ, Califf RM, et al, eds. Textbook of Cardiovascular Medicine. Section Two. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2007:Chap 23.

  5. Pierard LA, Lancellotti P. Stress testing in valve disease. Heart. Jun 2007;93(6):766-72. [Medline].

  6. Braunwald E. Valvular heart disease. In: AS Fauci, ed. Harrison's Principles of Internal Medicine. New York: McGraw Hill; 1994:1059-1061.

  7. Crawley IS, Morris DC, Silverman BD. Valvular heart disease. In: JW Hurst, ed. The Heart. 4th ed. New York: McGraw-Hill; 1978:922-1080.

  8. Edwards JE. Pathology of acquired valvular disease of the heart. Semin Roentgenol. 1979;14(2):96-115. [Medline].

  9. Fyler DC. Aortic stenosis. In: AS Nadas, DC Fyler, eds. Nadas Pediatric Cardiology. Philadelphia: Hanley and Belfus; 1992:493-511.

  10. Lam YY, Kaya MG, Li W, Gatzoulis MA, Henein MY. Effect of chronic afterload increase on left ventricular myocardial function in patients with congenital left-sided obstructive lesions. Am J Cardiol. Jun 1 2007;99(11):1582-7. [Medline].

  11. Lindroos M, Kupari M, Heikkila J, Tilvis R. Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample. J Am Coll Cardiol. 1993;21(5):1220-5. [Medline].

  12. Otto CM. Statins for aortic stenosis? Still waiting for answers. Nat Clin Pract Cardiovasc Med. Jul 2007;4(7):358-9. [Medline].

  13. Rahimtoola SH, Chandraratna PAN. Valvular heart disease. In: Clinical Medicine. Vol 6. 1983:1-51.

  14. Tzemos N, Therrien J, Yip J, Thanassoulis G, Tremblay S, Jamorski MT, et al. Outcomes in adults with bicuspid aortic valves. JAMA. Sep 17 2008;300(11):1317-25. [Medline].

  15. Welsh RC, Tymchak WJ. An unusual case of ST elevation in a 39-year-old man. Can J Cardiol. Feb 2000;16(2):215-7. [Medline].

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Further Reading

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Keywords

AS, aortic stenosis, congenital unicuspid or bicuspid valve, rheumatic fever, degenerative calcific changes of the valve, aortic valve, congestive heart failure, CHF, congenital cardiac defect, congenital heart defect, left ventricular failure, rheumatic disease, calcification of a congenital bicuspid valve, degenerative calcification of the valve

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Contributor Information and Disclosures

Author

Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas Hospital
Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Daniel P Lombardi, DO, Clinical Assistant Professor, New York College of Osteopathic Medicine; Clinical Preceptor, Albert Einstein College of Medicine of Yeshiva University; Attending Physician and Interim Program Director, Department of Emergency Medicine, Saint Barnabas Hospital
Daniel P Lombardi, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Medical Editor

Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Gary Setnik, MD, Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School
Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians and National Association of EMS Physicians
Disclosure: Intellicare Salary Management position; South Middlesex EMS Consortium Salary Management position

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Harvard Medical School; Associate-Chief, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Schering  Honoraria Speaking and teaching

 
 
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