What is the management approach for a patient with mild to moderate aortic stenosis, hiatal hernia, and Cameron's ulcer, considering their potential age and underlying health conditions?

Management of Mild to Moderate Aortic Stenosis

For patients with mild to moderate aortic stenosis, the cornerstone of management is serial echocardiographic surveillance combined with aggressive blood pressure control, patient education about symptom recognition, and consideration for concurrent valve replacement if other cardiac surgery becomes necessary. 1

Surveillance Strategy

Echocardiographic monitoring is mandatory and should be performed:

• Every 1-2 years for moderate aortic stenosis 1, 2
• Every 2-3 years for mild aortic stenosis in younger patients without calcification 3
• Every 3-5 years for mild aortic stenosis 2
• Annually for patients with mild or moderate AS who have significant calcium burden 3

The average hemodynamic progression is approximately 0.3 m/s increase in aortic velocity per year, though individual variability is substantial. 1 Predictors of rapid progression include older age, more severe valve calcification, and faster rate of hemodynamic changes on serial studies. 1

Blood Pressure Management

Aggressive treatment of hypertension is critical because the combination of aortic stenosis and hypertension creates "two resistors in series," significantly increasing cardiovascular morbidity and mortality. 1

• Renin-angiotensin system blockers are the preferred first-line agents 1
• Beta-blockers are appropriate if the patient has reduced ejection fraction, prior MI, arrhythmias, or angina 1
• Diuretics should be used sparingly, particularly if LV chamber dimensions are small 1

Patient Education and Symptom Monitoring

Patients must be educated to immediately report any symptoms of dyspnea, angina, or syncope. 1 This is critical because asymptomatic patients with moderate aortic stenosis have survival rates similar to age-matched controls, but once symptoms develop, average survival is significantly reduced. 1 The rate of symptom development is approximately 38% at 3 years for patients with initial jet velocity ≥2.6 m/s. 1

Management of Concurrent Conditions

Maintain normal sinus rhythm when possible, as loss of atrial kick significantly impairs ventricular filling in patients with diastolic dysfunction. 1 Correct anemia promptly to maintain adequate oxygen delivery. 1

Special Consideration: Concurrent Cardiac Surgery

If the patient requires coronary artery bypass grafting or other cardiac surgery, aortic valve replacement should be performed concurrently, even for moderate aortic stenosis, to avoid future reoperation. 1, 4

The rationale is compelling: if there is a measurable gradient >20-25 mmHg across the aortic valve in a patient requiring CABG, the patient is at considerable risk for developing symptomatic aortic stenosis before reaching the end of expected benefit from CABG. 4 If unoperated, aortic stenosis will worsen at an average of 6-8 mmHg per year (-0.1 cm²/year valve area), and one-quarter of such patients will require late AVR with high operative mortality (14-24%). 4 In contrast, performing AVR at the time of CABG increases operative risk only slightly (from 1-3% to 2-6%). 4

Indications for Cardiology Referral

Immediate cardiology referral is warranted if:

• Symptoms develop 1
• Echocardiography shows progression to severe aortic stenosis 1
• Left ventricular systolic dysfunction develops 1, 2
• BNP levels become elevated 1

Context for Hiatal Hernia and Cameron's Ulcer

In the specific context of a patient with hiatal hernia and Cameron's ulcer (erosions at the diaphragmatic impression on the stomach), anemia management becomes particularly important. 1 Cameron's ulcers can cause chronic gastrointestinal bleeding and anemia, which is especially problematic in aortic stenosis patients who already have compromised cardiac output. Prompt correction of anemia is essential to maintain adequate oxygen delivery in the setting of fixed cardiac output from aortic stenosis. 1

If the patient requires surgical repair of the hiatal hernia and has moderate aortic stenosis with a measurable gradient, consideration should be given to concurrent cardiac surgery consultation to evaluate whether prophylactic aortic valve replacement is warranted, though this would typically require the cardiac surgery to be the primary indication. 1, 4