A 64-year-old man comes to the office for a routine follow-up. He has no current concerns. Last year, he underwent a transthoracic echocardiogram for a cardiac murmur and was diagnosed with mild calcific aortic stenosis. The mean gradient across the valve was 18 mm Hg (normal

Question

A 64-year-old man comes to the office for a routine follow-up. He has no current concerns. Last year, he underwent a transthoracic echocardiogram for a cardiac murmur and was diagnosed with mild calcific aortic stenosis. The mean gradient across the valve was 18 mm Hg (normal <5 mm Hg) , and the estimated valve area was 1.6 cm² (normal 3-4 cm²) . The patient does not use tobacco, alcohol, or illicit drugs. He jogs and bikes 3 times a week.
Blood pressure is 136/78 mm Hg, and pulse is 77/min and regular. BMI is 29 kg/m². A 3/6 systolic ejection-type murmur is heard at the upper sternal border radiating to the carotids. S4 is heard at the apex at end-expiration. Lungs are clear to auscultation. The remainder of the examination is unremarkable.
ECG shows normal sinus rhythm with voltage criteria for left ventricular hypertrophy and nonspecific ST segment changes.
Laboratory results are as follows:

What is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9755_9b0e_853d_f36b86030fe9_MD0002_00 This patient with aortic stenosis (AS) has asymptomatic and mild (ie, transvalvular velocity 2-2.9 m/s, mean transvalvular gradient <20 mm Hg) valvular disease. Progression of AS is quite variable; however, the aortic valve area declines at an average rate of 0.1 cm²/year in most patients. Most patients with mild to moderate AS remain asymptomatic for several years and should have routine clinical evaluation (eg, annually) to assess for new symptoms or signs of worsening AS. ² Patients with asymptomatic, mild AS should undergo serial echocardiogram every 3-5 years. Those with moderate AS should undergo echocardiogram every 1-2 years, and those with severe AS should have an echocardiogram every 6-12 months. Echocardiogram should be performed earlier than the standard interval if patients develop any new signs or symptoms of worsening AS (eg, chest pain, dyspnea, lower extremity edema, lightheadedness, syncope). (Choice A) Pharmacologic therapy has no role in the management of patients with asymptomatic, mild AS. Beta blockers can be used in patients with mild to moderate AS and concurrent hypertension, coronary artery disease, or heart failure. (Choice B) Antibiotic prophylaxis for endocarditis is indicated only for patients with the highest-risk cardiac conditions. It is not indicated in most patients with valvular heart disease, including those with bicuspid aortic valve and AS. highest-risk cardiac conditions (Choice D) Unless symptoms consistent with worsening AS develop, echocardiogram is not indicated for another 2-4 years in this patient with mild AS. (Choice E) There is no role for routine exercise stress testing in patients with asymptomatic, mild AS. It is occasionally performed in patients with asymptomatic, severe AS to confirm absence of symptoms. Educational objective: Serial echocardiogram is recommended every 3-5 years in patients with mild aortic stenosis (AS), every 1-2 years in those with moderate AS, and every 6-12 months in those with asymptomatic, severe AS. Pharmacologic therapy has no role in the management of patients with mild AS in the absence of concurrent hypertension, coronary artery disease, or heart failure. __________ References: 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/24603191) Medical therapy for calcific aortic stenosis. (http://www.ncbi.nlm.nih.gov/pubmed/21828284)

A 64-Year-Old Man Comes to the Office for a Routine