ACP InternistMKSAP Quiz: Dyspnea, Exertional Syncope

Is it time for cardiac catheterization, CT of the aortic valve, exercise stress testing, surgical aortic valve replacement, or transcatheter aortic valve implantation in this aortic stenosis patient?

A 75-year-old man presents with dyspnea and an episode of exertional syncope. Clinical examination reveals aortic stenosis. An ECG shows normal sinus rhythm and left ventricular hypertrophy with repolarization abnormalities. The echocardiogram reveals a severely thickened, minimally mobile tricuspid aortic valve compatible with severe aortic stenosis. However, hemodynamic data from echocardiography show a mean aortic gradient and aortic valve area consistent with moderate aortic stenosis. Left ventricular ejection fraction is greater than 55%, and stroke volume index is normal.

Which of the following is the most appropriate next step in management?

• Cardiac Catheterization. Cardiac catheterization is a procedure that can provide further hemodynamic testing. It is often used when there is a discrepancy between the clinical evaluation and the echocardiogram.
• CT of the Aortic Valve. CT of the aortic valve is a diagnostic modality for severe aortic stenosis in low-flow, low-gradient disease with normal or reduced cardiac output.
• Exercise Stress Testing. Exercise stress testing is a diagnostic tool used to assess the heart’s response to stress or exercise.
• Surgical Aortic Valve Replacement. Surgical aortic valve replacement is a procedure where the diseased aortic valve of the heart is replaced with a graft.
• Transcatheter Aortic Valve Implantation. Transcatheter aortic valve implantation is a minimally invasive surgical procedure repairs the valve without removing the old, damaged valve.

According to the American Heart Association, aortic stenosis is one of the most common and most serious valve disease problems. An estimated 2.5 million people over age 75 in the United States suffer from this condition.

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