What is the diagnosis and treatment for pulsus parvus et tardus, often associated with aortic stenosis?

From the Guidelines

Pulsus parvus et tardus is a clinical finding that strongly suggests aortic stenosis, and the most recent and highest quality evidence recommends valve replacement as the definitive treatment for symptomatic or severe stenosis. The diagnosis involves detecting this abnormal pulse pattern during physical examination, followed by confirmation with echocardiography, which is the gold standard for diagnosing aortic stenosis 1. The echocardiogram will typically show a thickened, calcified aortic valve with reduced opening and increased pressure gradient across the valve.

Diagnosis and Treatment

Treatment depends on symptom severity and stenosis degree. For mild to moderate asymptomatic stenosis, watchful waiting with regular follow-up is appropriate. For symptomatic or severe stenosis, valve replacement is the definitive treatment, either through surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) 1. Medical management includes avoiding strenuous activity, treating hypertension cautiously (using low doses of ACE inhibitors or ARBs), and managing heart failure symptoms with diuretics if present.

Medical Management

According to the most recent evidence, hypertension is a risk factor for AS and associated with increased rate of progression and reduced survival 1. It increases LV afterload and thereby LV mass, which is independently associated with mortality. Given that AS-related afterload may only be modified by valve intervention, treatment of hypertension is a valid target. The recommended treatment targets are a systolic blood pressure of 130–139 mmHg and a diastolic blood pressure of 70–90 mmHg 1.

Valve Replacement

The choice between SAVR and TAVR depends on the patient's surgical risk, with TAVR being recommended for patients with prohibitive surgical risk or high surgical risk 1. The current European Society of Cardiology (ESC) guidelines indicate valve replacement for those patients with severe AS who have symptoms, impaired LV systolic function (ejection fraction <50%), or in whom other cardiac surgery is being performed 1.

Key Points

• Pulsus parvus et tardus is a clinical finding that strongly suggests aortic stenosis
• Valve replacement is the definitive treatment for symptomatic or severe stenosis
• Medical management includes avoiding strenuous activity, treating hypertension cautiously, and managing heart failure symptoms
• The choice between SAVR and TAVR depends on the patient's surgical risk
• Treatment of hypertension is a valid target to reduce the progression of AS and improve survival 1

From the Research

Definition and Diagnosis of Pulsus Parvus et Tardus

• Pulsus parvus et tardus is a clinical finding characterized by a small, weak pulse with a delayed systolic peak, often associated with aortic stenosis (AS) 2.
• The diagnosis of pulsus parvus et tardus can be supported by the analysis of radial arterial pressure curves, which may show a prolonged time difference between the peak of left ventricular and aortic systolic pressures (TLV-Ao) 3.
• The aortic pulse contour can also be affected by factors such as aging, hypertension, and increased peripheral arterial elastance, making it essential to consider these factors when interpreting the pulse contour in patients with AS 4.

Association with Aortic Stenosis

• Pulsus parvus et tardus is a well-recognized clinical finding of aortic stenosis (AS), and its presence can indicate significant AS 2.
• The occurrence of pulsus tardus can be associated with not only AS severity but also left ventricular systolic dysfunction in AS patients 3.
• The central aortic pressure waveform can provide valuable information on the severity of AS, and changes to arterial properties and pulse wave velocity can cause profound changes to the contour 5.

Treatment and Management

• The treatment of pulsus parvus et tardus typically involves addressing the underlying cause, such as aortic stenosis, through surgical or transcatheter aortic valve replacement 6.
• Echocardiography plays a crucial role in the diagnosis and evaluation of aortic stenosis, and standards should be adopted to maintain accuracy and consistency across echocardiographic laboratories 6.
• A comprehensive assessment of aortic stenosis should include the optimization of left ventricular outflow tract assessment, low flow, low gradient aortic stenosis with preserved ejection fraction, and a grading algorithm for an integrated and stepwise approach of aortic stenosis assessment in clinical practice 6.