, 20 tweets, 8 min read Read on Twitter
I’ve been musing re aortic stenosis so it’s #periopmedicine #tweetorial #MedThread time!
This is a composite of multiple patient encounters w common themes:
Goals:
-review periop guidelines re aortic stenosis
-some physical exam teaching
-discuss role of patient counseling 1/N
2/N
First, how good are we at diagnosing severe AS by exam?
3/N Hypothetically:
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?
4/N Very commonly, I hear—“I have a murmur, and I was told I didn’t need to worry about it”
while there certainly are “benign” or “non-pathologic” murmurs, including those that are long standing and never correlate with valve disease by ECHO…
5/N The “I was told I didn’t need to worry about it” almost always gives me pause.
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
6/N I also worry about the “I’ve had it for so long, I was born with it!”
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
7/N And sometimes, I find a prior ECHO with mild or moderate aortic stenosis…and maybe that ECHO is 2, 4, 6 years old. Now what?
8/N first, how common is aortic stenosis?
Olmstead Country data showed Aortic stenosis increased from prevalence of 1.4% 65-74yo to 4.6% 75 and older
sciencedirect.com/science/articl…
9/N In the 2007 ACC/AHA guidelines, severe aortic stenosis was one of the “active” conditions
in the algorithm flow chart itself
10/N Publications several years later provided new mortality/morbidity data, with event rates now in the single digits v the double digits.
Symptomatic v asymptomatic disease also emerged as a variable.

ahajournals.org/doi/full/10.11…
academic.oup.com/eurheartj/arti…
11/N Agarwal et al also raised an association with increased complication
rates with moderate aortic stenosis
ahajournals.org/doi/full/10.11…
12/N
The 2014 ACC/AHA guidelines expanded the recommendation for testing to aortic stenosis (and regurgitation) in addition to adding MR to MS, and expanded testing criteria to concern for moderate disease
severe asymptomatic AS was also not a barrier to surgery
13/N the European guidelines provide this guidance academic.oup.com/eurheartj/arti…
14/N
Btw, there was a new @ConsultGuys module last month about severe aortic stenosis before surgery
@AnnalsofIM
annals.org/aim/fullarticl…
15/N
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
16/N
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
17/N
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
18/N
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!
@andremansoor thoughts?
19/N
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”
20/N so in summary
-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
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