What is the appropriate workup for a 70-year-old female with first-degree (grade 1) atrioventricular (AV) block, syncopal episodes, aortic regurgitation, left ventricular hypertrophy, and grade 2 diastolic dysfunction?

From the Guidelines

For a 70-year-old female with grade 1 heart block, syncopal episodes, aortic regurgitation, left ventricular hypertrophy, and grade 2 diastolic dysfunction, I strongly recommend a pacemaker implantation and referral to a cardiologist, specifically an electrophysiologist, for further management. This recommendation is based on the high risk of progression of heart block and the potential for hemodynamic compromise from aortic regurgitation, which can lead to reduced cardiac output and increased morbidity and mortality 1.

Comprehensive Cardiac Workup

A comprehensive cardiac workup should include:

• A 12-lead ECG to assess the heart block and rhythm disturbances
• A 24-48 hour Holter monitor to capture any intermittent arrhythmias that may be causing syncope
• An echocardiogram to evaluate the severity of aortic regurgitation, degree of LV hypertrophy, and diastolic dysfunction
• Exercise stress testing to assess functional capacity and symptoms with exertion
• Cardiac MRI to provide detailed assessment of ventricular function and regurgitation severity
• Laboratory tests, including electrolytes, renal function, thyroid function, and brain natriuretic peptide (BNP)

Management of Aortic Regurgitation

According to the European Heart Journal, medical therapy for chronic aortic regurgitation (AR) may provide symptomatic improvement in patients with severe AR in whom surgery is not feasible 1. However, given the patient's symptoms and grade 2 diastolic dysfunction, surgical intervention, such as aortic valve replacement (AVR), should be considered. The decision to proceed with surgery should be made in consultation with a cardiologist and cardiothoracic surgeon, taking into account the patient's overall health status and surgical risk.

Management of Syncope

For the syncopal episodes, tilt-table testing and carotid sinus massage (if no carotid bruits) should be considered. Depending on findings, a loop recorder implantation may be warranted to correlate symptoms with cardiac rhythm 1.

Referral to Specialist

The patient should be referred to a cardiologist, specifically an electrophysiologist, given the combination of conduction abnormalities and syncope. This comprehensive evaluation is crucial as the syncope could be related to progression of heart block, hemodynamic compromise from aortic regurgitation, or diastolic dysfunction leading to reduced cardiac output.

From the Research

Patient Profile

• 70-year-old female patient
• Grade 1 heart block
• Syncopal episodes
• Aortic regurgitation
• Left ventricular hypertrophy
• Grade 2 diastolic dysfunction

Relevant Studies

• A study from 2 found that in asymptomatic patients with severe aortic regurgitation and normal left ventricular function, the presence of severe left ventricular dilatation did not influence the progression of left ventricular enlargement or hypertrophy, suggesting that close follow-up could delay surgery in this population.
• Research from 3 showed that in chronic aortic regurgitation, eccentric hypertrophy with combined concentric hypertrophy of the left ventricle is an adaptive response to volume overload, but progressive dilatation leads to depressed left ventricular contractility and myocardial structural changes.
• A study published in 4 identified unique remodeling signatures that might differentiate the etiology of left ventricular hypertrophy, with aortic stenosis characterized by a left-right axis shift and decreased short-axis eccentricity.
• Findings from 5 indicated that left ventricular volume is a strong predictor of clinical outcomes in patients with aortic regurgitation, with indexed left ventricular end-systolic volume ≥ 45 mL/m2 associated with worse outcomes.
• According to 6, left ventricular hypertrophy in valvular aortic stenosis is a significant concern, as its regression after aortic valve replacement is often incomplete and associated with adverse outcomes, suggesting that consideration of structural abnormalities may be important for optimal timing of aortic valve replacement.

Key Considerations

• Left ventricular hypertrophy and aortic regurgitation are significant factors in determining patient outcomes
• Close monitoring and consideration of left ventricular volume and function may be crucial in managing patients with aortic regurgitation
• The presence of severe left ventricular dilatation may not necessarily influence the progression of left ventricular enlargement or hypertrophy in asymptomatic patients with severe aortic regurgitation and normal left ventricular function
• Unique remodeling signatures may help differentiate the etiology of left ventricular hypertrophy, with implications for treatment and management.