A 67-year-old man comes to the office for routine follow-up. He has a history of hypertension, osteoarthritis, and chronic aortic regurgitation. He reports that he is doing well overall and plays doubles tennis three times a week for exercise, which he does without any chest pain or pressure. He denies shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, or edema. His medications include aspirin, nebivolol, simvastatin, chlorthalidone, and acetaminophen.
His blood pressure is 128/60 mm Hg and pulse is 67 /min. His BMI is 27 kg/m². Cardiovascular examination reveals a normal S1 and S2. There is 2/6 mid-systolic murmur at the right upper sternal border followed by a high-pitched diastolic decrescendo murmur best heard at the left upper sternal border. The intensity of the diastolic murmur is increased with handgrip. His peripheral pulses are 3+ bilaterally.
A transthoracic echocardiogram demonstrates normal left ventricular size and function. The aortic valve is calcified and demonstrates mild stenosis (mean gradient = 13 mm Hg) with moderate aortic regurgitation. When compared to the echocardiogram from two years ago, both the aortic stenosis and regurgitation are worse.
Which of the following would be the most appropriate next step?

Question

Quizplus · Accepted Answer

This patient presents with asymptomatic mixed aortic valve disease, predominantly moderate aortic regurgitation (AR) seen on echocardiography (ECHO). Current guidelines recommend isolated aortic valve replacement for severe AR in symptomatic patients (i.e., shortness of breath, decreased exercise tolerance) and asymptomatic patients with abnormal ECHO findings (e.g., ejection fraction < 50% or a dilated left ventricle with either end-diastolic size > 75 mm or end-systolic size > 55 mm). 11ec193a_9734_cc68_853d_c343e72ee6e5_MD0002_00 Vasodilators (ACEI or nifedipine) are indicated for severe AR in symptomatic patients with left ventricular (LV) dysfunction who are not surgical candidates for valve replacement. Symptomatic patients awaiting surgery should receive intense medical therapy with digoxin, diuretics, and vasodilators to help decrease congestive symptoms prior to surgery. Patients who do not meet surgical or medical therapy criteria need re-evaluation for symptoms and a repeat echocardiogram in 6-12 months. Patients with mild AR and normal LV function need only a yearly clinical evaluation and repeat ECHO every 2-3 years. There are no formal guidelines for patients with moderate AR, but most clinicians would re-evaluate the patient clinically every 6-12 months with repeat ECHO at each visit as clinically indicated (especially in patients who show progressive disease, such as this one). (Choice A) This patient only has moderate regurgitation and mild stenosis. Even if the valvular disease were severe, he does not meet any current criteria for valve replacement (i.e., symptomatic, dilatation, or LV dysfunction). (Choice B) Coronary angiography would only be needed if the patient were having symptoms of ischemic heart disease, or if the noninvasive tests were inconclusive to determine the valve severity. Coronary angiography is also needed prior to valve surgery to determine if coronary revascularization is required simultaneously. (Choice C) Lisinopril, an ACEI, is also a vasodilator that can be helpful for patients with decompensated heart failure from aortic regurgitation. However, they are not indicated for the long-term management of asymptomatic patients with mild to moderate aortic regurgitation and normal systolic function (such as this patient). (Choice E) Transesophageal echocardiograms (TEE) can be useful to get more detailed images of the left-sided valves in instances such as endocarditis or prosthetic valve dysfunction. They are rarely better than transthoracic echocardiograms (TTE) for estimating valve severity in native valves. Educational objective: Valve replacement in patients with chronic severe aortic regurgitation should be considered based upon the development of symptoms or left ventricular dilatation/dysfunction. In the absence of those findings, close clinical follow up and echocardiograms every 6-12 months are warranted. __________ References: Usefulness of preoperative stroke volume as strong predictor of left ventricular remodeling and outcomes after aortic valve replacement in patients with severe pure aortic regurgitation. (http://www.ncbi.nlm.nih.gov/pubmed/21798497)

A 67-Year-Old Man Comes to the Office for Routine Follow-Up