First, how good are we at diagnosing severe AS by exam?
patient comes for a preop evaluation/risk assessment (not “clearance”) and reports a history of a murmur
You ask more Qs-how long have you know, what have you been told about it, when was your last ECHO, what kind of follow-up were you were told you needed?
while there certainly are “benign” or “non-pathologic” murmurs, including those that are long standing and never correlate with valve disease by ECHO…
Was that “don’t worry about it…EVER” or “don’t worry about it now but we need to followup in 1 to 2 to 3 years…”
Big difference for continuity care needs
What kind of murmurs are that lifelong and reflect congenital disease?
For the purposes of this tweetorial, I’m looking at you, bicuspid aortic valves, which have an earlier progression to severe AS
Olmstead Country data showed Aortic stenosis increased from prevalence of 1.4% 65-74yo to 4.6% 75 and older
rates with moderate aortic stenosis
While “ > 4 METS” isn't part of the “ECHO for valve disease” guidelines, v the ischemic eval, symptomatic/asymptomatic is a branch point in the 2014 guidelines
I use my history to eval for any cardiopulmonary symptoms—dyspnea,
angina, presyncope, edema, orthopnea/PND
I also use my exam—quality,
pitch, “shape”, timing during systolic (or diastolic), timing of pulse,
radiation across precordium, I also look carefully at JVP and for edema
So let’s say I’ve asked the patient all these questions—and no concerning symptoms
Let’s say they look euvolemic on exam
I’m feeling pretty reassured—my pretest probability for severe AS (certainly symptomatic severe AS) feels low so far…And then I listen to the murmur
Maybe it’s 1-2/6, restricted to the RUSB, no radiation across the precordium,
BUT, maybe it’s harsh, late systolic, radiates across precordium and to the carotids.
From Dr. Steve McGee’s book—the +LRs are all actually all pretty low!
When I’m worried about a murmur, how do I tell a patient?
“I need more info before your surgery to empower your periop care. Even if it’s not a barrier to surgery, this will empower you with long term information about your health that I will let your PCP know about”
-know the guidelines
-know the operating characteristics of your exam maneuvers
-know how to counsel a patient re needing an ECHO
-know how to interpret “I was told not to worry about it”
-and empower your own patients about future monitoring needs