What is a good template for an illness script for aortic stenosis for medical students?

From the Guidelines

A good template for an aortic stenosis illness script should prioritize the most recent and highest quality evidence, focusing on epidemiology, pathophysiology, clinical presentation, diagnostic findings, and management, with an emphasis on the 2021 ACC/AHA guideline for the management of patients with valvular heart disease 1.

Epidemiology and Pathophysiology

• Aortic stenosis is the most common valvular heart disease in developed countries, affecting 2-7% of people over 65, with risk factors including age, male gender, hypertension, diabetes, and bicuspid aortic valve (present in 1-2% of the population) 1.
• The pathophysiology involves progressive calcification and narrowing of the aortic valve, leading to left ventricular outflow obstruction, increased afterload, compensatory left ventricular hypertrophy, and eventually heart failure.

Clinical Presentation and Diagnostic Findings

• Classic clinical presentation includes the triad of exertional chest pain (angina), syncope, and heart failure symptoms (dyspnea, fatigue, orthopnea), along with a harsh crescendo-decrescendo systolic murmur at the right upper sternal border radiating to the carotids, delayed carotid upstroke (pulsus parvus et tardus), and possibly an S4 gallop.
• Diagnostic findings include an echocardiogram showing valve calcification, reduced valve area (<1.0 cm²), increased transvalvular gradient (mean gradient >40 mmHg in severe AS), and left ventricular hypertrophy, while ECG may show left ventricular hypertrophy and chest X-ray might reveal a dilated ascending aorta or calcified aortic valve.

Management

• Management of aortic stenosis should be based on the latest guidelines, which recommend valve replacement (surgical or transcatheter aortic valve replacement) for symptomatic severe AS, with medical therapy used cautiously for symptom management but not altering disease progression 1.
• The choice of intervention should be a shared decision-making process that considers the lifetime risks and benefits associated, with earlier intervention considered if indicated by results of exercise testing, biomarkers, rapid progression, or the presence of very severe stenosis 1.
• Asymptomatic patients should be monitored, while symptomatic severe AS requires prompt intervention to improve morbidity, mortality, and quality of life.

From the Research

Illness Script Template for Aortic Stenosis

Definition and Epidemiology

• Aortic stenosis is a common valvular heart disease characterized by the narrowing of the aortic valve orifice, leading to a systolic pressure drop between the left ventricle and ascending aorta 2.
• The incidence of aortic stenosis increases with age, and it is the most frequent reason for prosthetic valve replacement in adults 2.

Pathogenesis and Risk Factors

• The most common form of aortic stenosis is degenerative-calcific, which is related to atherosclerotic risk factors 2.
• The disease process involves an active inflammatory process with features similar to atherosclerosis 3.

Clinical Presentation

• Typical symptoms of severe aortic stenosis include dyspnea, angina, and dizziness or syncope 2, 4.
• Patients with symptoms have a higher mortality rate than asymptomatic patients 4.

Diagnosis

• The most important diagnostic technique is echocardiography, which allows measurement of the gradient and calculation of the orifice area to determine the degree of severity 2.
• Transthoracic echocardiogram is the test of choice, but point-of-care ultrasound can be used when a formal echocardiogram is not feasible 4.

Management

• The development of symptoms or impaired left ventricular function in severe aortic stenosis should prompt surgical treatment by valve replacement 2, 4.
• Truly asymptomatic patients with preserved left ventricular function should be followed conservatively 2.
• Emerging medical treatments, such as statins and angiotensin converting enzyme inhibitors, may hold promise in modifying the disease process, but definitive evidence is awaited 5.

Treatment Options

• Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) are treatment options for severe symptomatic aortic stenosis 6.
• Medical management may be selected for patients who are not candidates for valve replacement, with physician-reported reasons including patient preference, medical futility, and inoperability/anatomic infeasibility 6.