Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Aortic Stenosis

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In one line

·The aortic valve has narrowed, forcing the left ventricle to generate dangerously high pressure to push blood through.

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Normal physiology

·The aortic valve opens during systole (when the left ventricle squeezes) to let oxygen-rich blood leave the heart and enter the aorta, then closes during diastole (when the ventricle relaxes) to prevent backflow and maintain pressure in the aorta that feeds the coronary arteries. A normal valve has three thin, flexible leaflets and opens to 3–4 cm² (about the size of a nickel).

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What goes wrong

·The aortic valve opening shrinks because the leaflets thicken, stiffen, and fuse together—like a door hinge that rusts and won't open all the way.

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Hallmark signs

·Shortness of breath with activity (exertional trouble breathing (dyspnea))
·Chest pressure or pain during activity (angina)
·Fainting or feeling dizzy during exercise (exertional fainting (syncope))
·Tiring easily and stopping activity sooner than before
·Trouble breathing when lying flat or waking up gasping at night
·Harsh heart murmur that gets louder then softer, heard at the upper right chest
·Weak, slow pulse in the neck (pulsus parvus et tardus)
·Sudden death without warning

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Red flags · escalate now

·Fainting or near-fainting during exercise (the heart cannot supply enough blood; sudden death risk is very high)
·New or worse shortness of breath, leg swelling, or trouble lying flat in someone with known aortic narrowing (stenosis) (the heart is failing and the valve must be replaced urgently)
·Chest pain at rest or with only light activity (the heart muscle is starving for oxygen and can die)
·Fast, irregular heartbeat (atrial fibrillation) in a patient with aortic narrowing (stenosis) (losing the normal atrial squeeze can crash blood pressure and cause shock)
·Low blood pressure or shock after taking water pills or blood-pressure medicines (the heart depends on high filling pressure; sudden loss of fluid can stop the pump)

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Workup

·Transthoracic echocardiography (TTE)
·CT calcium scoring of the aortic valve and aortic root
·Brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP)
·Exercise stress test (treadmill or bike, only if the patient has severe AS by echo but reports no symptoms)
·Cardiac catheterization with direct pressure measurement across the aortic valve
·Electrocardiogram (ECG)
·Chest X-ray
·Coronary angiography (before surgical aortic valve replacement in adults ≥40 years or with cardiac risk factors)

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Treatment

·Aortic valve replacement (surgical AVR or transcatheter TAVR)
·Avoid rapid vasodilators (nitrates, ACE inhibitors, ARBs) and maintain adequate preload in severe symptomatic AS before valve replacement
·Diuretics (e.g., furosemide 20–40 mg PO or IV) for pulmonary congestion or volume overload
·Endocarditis prevention (prophylaxis) (amoxicillin 2 g PO or ampicillin 2 g IV 30–60 minutes before dental procedures) ONLY if prosthetic valve is present
·Serial echocardiography every 6–12 months for asymptomatic severe AS; every 1–2 years for moderate AS
·Treat high blood pressure (hypertension) cautiously with beta-blockers or calcium channel blockers (avoid rapid afterload reduction)
·Treat atrial fibrillation (an irregular, quivering heartbeat) with rate control and anticoagulation (but avoid aggressive rate control that drops cardiac output)

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NCLEX trap

·Never give vasodilators in severe aortic narrowing (stenosis). The narrowed valve makes it hard for blood to leave the left ventricle. The thick, stiff heart muscle depends on high filling pressure to push enough blood through that tiny opening. Vasodilators drop blood pressure and filling pressure, and suddenly the heart cannot pump enough blood to the brain and body—this causes collapse (sudden dangerous drop in blood pressure and blood flow). Instead, use a beta-blocker to slow the heart rate so the ventricle has more time to fill and eject blood through the narrow valve.
·Location is the key. Aortic narrowing (stenosis) makes a harsh systolic murmur loudest at the right upper sternal border (right side of the breastbone near the collarbone) that travels up into the neck arteries (carotids). Mitral regurgitation is loudest at the apex (lower left chest, under the nipple). Always note where the murmur is loudest and where it spreads to tell them apart.
·Once symptoms start in severe aortic narrowing (stenosis)—chest pain, fainting, or shortness of breath—half of patients die within two years if the valve is not replaced (AHA/ACC guidelines). Symptoms mean the heart can no longer compensate for the narrow valve. Refer urgently to cardiology for valve replacement (TAVR or SAVR). Do not delay.
·The most common cause today is calcific aortic narrowing (stenosis) (calcium deposits harden the valve) in adults over 65. But younger adults—often in their 40s and 50s—can have aortic narrowing from a bicuspid aortic valve (a birth defect where the valve has two flaps instead of three). Bicuspid valves wear out and narrow faster. Always check the echocardiogram for valve structure and ask about family history.
·In aortic narrowing (stenosis), the thick, stiff left ventricle needs high filling pressure to squeeze blood through the narrow valve. If you give too much diuretic, filling pressure drops, stroke volume (blood pumped per beat) falls, and cardiac output (total blood pumped per minute) crashes. Use diuretics very carefully in small doses, and watch blood pressure, heart rate, and oxygen closely. If the patient gets dizzy or blood pressure drops, stop the diuretic.
·Aortic narrowing (stenosis) causes a narrow pulse pressure (small gap between systolic and diastolic pressure) because less blood leaves the heart with each beat. For example, a blood pressure of 120/100 mmHg (pulse pressure only 20 mmHg) is typical. Compare that to aortic regurgitation, where pulse pressure is wide—like 160/50 mmHg. Narrow pulse pressure in aortic narrowing matches the reduced stroke volume from the tight valve opening.

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