主动脉瓣狭窄管理指南英文版.ppt

1、Aortic Stenosis,2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease,Department 1 of Cardiovascular Medicine, GD2H,Chen Wuqi,Aortic Stenosis,1. Stages of Valular AS 2. Diagnoses and Follow-Up 3. Medical Therapy 4. Timing of Intervention 5. Choice of Intervention,1.Stages

2、 of Valular AS,1.1. 4 Stages stage A: risk of AS stage B: progressive AS stage C: asymptomatic severe AS stage D: symptomatic severe AS,1.Stages of Valular AS,1.2. Defines by 4 factor a. valve anatomy calcification, reduced leaflet opening b. valve hemodynamics peak aortic valve velocity, mean aorti

3、c valve gradient c. hemodynamic consequences LV diastolic dysfunsion, LV hypertrophy, LVEF descrease, LV chamber d. patient symptoms exertional dyspnea, angina, heart failure, syncope,2.Diagnosis and Follow-Up,2.1 Initial Diagnosis TTE (transthoracic echocardiography) Low-dose dobutamine stress test

4、ing 2.2 Changing Signs or Symptoms 2.3 Routine Follow-Up 2.4 Cardiac Catheterization 2.5 Exercise Testing,2.Diagnosis and Follow-Up,2.1 Initial Diagnosis 2.1.1 TTE (Class I, B) concern bicuspid aortic valve, cause, LV size, systolic function, maximum transvalvular velocity, mean pressure gradient, c

5、ontinuity equation valve area timing an unexplained systolic murmur, a single second heart sound, a historyof a bicuspid aortic valve, symptoms that might be due to AS,2.Diagnosis and Follow-Up,2.1 Initial Diagnosis 2.1.2 Low-dose dobutamine stress testing (Class I, B) in patients with stages D2 AS:

6、 a. Calcified aortic valve with reduced systolic opening; b. LVEF less than 50%; c. Calculated valve area 1.0 cm2 or less; and d. Aortic velocity less than 4.0 m per second or mean pressure gradient less than 40 mm Hg.,2.Diagnosis and Follow-Up,2.1 Initial Diagnosis 2.1.2 Low-dose dobutamine stress

7、testing (Class I, B): a. beginning at 5 mcg/kg per minute b. increasing in increments of 5 mcg/kg per minute c. maximum dose of 20 mcg/kg per minute Definition of severe AS a maximum velocity 4.0 m/s with a valve area 1.0 cm2 true sever AS progressive AS 3th group aortic velocity 4.0 m/s 1.0 cm2 20%

8、 20% 20%,2.Diagnosis and Follow-Up,2.2 Changing Signs or Symptoms louder systolic murmur change in the second heart sound symptoms occur that might be due to AS noncardiac surgery repeat TTE pregnancy anemia gastrointestinal bleeding,2.Diagnosis and Follow-Up,2.3 Routine Follow-Up Stage vmax(m/s) de

9、velop intervals B 2-2.9 10%/5y 3-5y 3-3.9 0.3m/s/y 1-2y C 4 50-70%/2y 0.5-1y,2.Diagnosis and Follow-Up,2.4 Cardiac Catheterization noninvasive data nondiagnostic/discrepancy concern transaortic pressure gradients aortic valve area coronary angiography,2.Diagnosis and Follow-Up,2.5 Exercise Testing S

10、tage C (Class II, B) a.asymptomatic patients b.a calcified aortic valve c.aortic velocity 4.0 m/s d.mean pressure gradient 40 mm Hg Stage D (Class III, B),2.Diagnosis and Follow-Up,2.5 Exercise Testing positive testing results in 29% of asymptomatic patients 51 % of them developed symptoms over the

11、next year positive: stage C stage D1 concern symptoms limited exercise capacity abnormal BP response (hypotension or 80% of patients with AS),3.Medical Therapy,3.1 Antihypertension (Class I, B) hypertension in stage A, stage B, stage C reduces the total pressure overload attention standard GDMT (gui

12、deline-direted medical therapy) started at a low dose, gradually titrated upward frequent clinical monitoring (symptoms) no specific indication diuretics should be avoided if the LV chamber is small Beta Mockers are appropriate in patients with concurrent CAD.,3.Medical Therapy,3.2 Vasodilator thera

13、py (Class IIb, C) severe AS and NYHA class IV HF Invasive monitoring: LV filling pressures, cardiac output, systemic vascular resistance attension: a sudden decline in systemic vascular resistance might result in an acute decline in cardiac output 3.3 Statin therapy (Class III),4.Timing of Intervent

14、ion,4.Timing of Intervention,Class I 1. AVR is recommended in symptomatic patients with severe AS (stage D1) with (LOE B): a. Decreased systolic opening of a calcified or congenitally stenotic aortic valve; and b. An aortic velocity 4.0 m per second or greater or mean pressure gradient 40 mm Hg or h

15、igher; and c. Symptoms of HF, syncope, exertional dyspnea, angina, or presyncope by history or on exercise testing.,4.Timing of Intervention,Class I 2. AVR is recommended for asymptomatic patients with severe AS (stage C2) with (LOE: B): a. Decreased systolic opening of a calcified aortic valve; and

16、 b. LVEF less than 50 %; and c. an aortic velocity 4.0 m per second or greater or mean pressure gradient 40 mm Hg or higher (136, 137).,4.Timing of Intervention,Class I 3. AVR is indicated for patients with severe AS (stage C or D) when undergoing cardiac surgery for other indications when (LOE: B):

17、 a. calcified aortic valve; and b. decreased systolic opening; and c. aortic velocity 4.0 m per second or greater or mean pressure gradient 40 mm Hg or higher,4.Timing of Intervention,Class IIa 1. AVR is reasonable for asymptomatic patients with very severe AS (stage C1) with (LOE: B): a. Decreased

18、systolic opening of a calcified valve; b. An aortic velocity 5.0 m per second or greater or mean pressure gradient 60 mm Hg or higher; and c. A low surgical risk.,4.Timing of Intervention,Class IIa 2. AVR is reasonable in apparently asymptomatic patients with severe AS (stage C1) with (LOE: B): a. A

19、 calcified aortic valve; b. An aortic velocity of 4.0 m per second to 4.9 m per second or mean pressure gradient of 40 mm Hg to 59 mm Hg; and c. An exercise test demonstrating decreased exercise tolerance or a fall in systolic BP.,4.Timing of Intervention,Class IIa 3. AVR is reasonable in symptomati

20、c patients with low-flow/low-gradient severe AS with reduced LVEF (stage D2) with a (LOE: B): a. Calcified aortic valve with reduced systolic opening; b. Resting valve area 1.0 cm2 or less; c. Aortic velocity less than 4 m per second or mean pressure gradient less than 40 mm Hg; d. LVEF less than 50

21、%n;and e. A low-dose dobutamine stress study that shows an aortic velocity 4 m per second or greater or mean pressure gradient 40 mm Hg or higher with a valve area 1.0 cm2 or less at any dobutamine dose.,4.Timing of Intervention,Class IIa 4. AVR is reasonable in symptomatic patients with low-flow/lo

22、w-gradient severe AS (stage D3) with an normal LVEF, a calcified aortic valve with significantly reduced leaflet motion, and a valve area 1.0 cm2 or less only if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms and data recorded when the patient is normotensive indicate (LOE: C): a. An aortic velocity less than 4 m per second or mean pressure gradient less than 40 mm Hg; and b. A strok