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Aortic Stenosis Aortic Obstruction
Source: Disturbances Of The Heart
Valvular disease at the aortic orifice is much less common than at
the mitral orifice, and while stenosis or obstruction is less common
from rheumatism or acute inflammatory endocarditis than is
insufficiency of this valve, a narrowing or at least the clinical
sign of narrowing, denoted by a systolic blow at the base of the
heart over the aortic opening, is in arteriosclerosis and old age of
frequent occurrence. If such narrowing occurs without aortic
insufficiency at the age at which it usually occurs, it may not
seriously affect the heart. It may follow acute endocarditis, but it
most frequently follows chronic endocarditis or atheroma, in which
the aortic valves become thickened and more or less rigid; this
condition most frequently occurs in men.
Anything that tends to increase arterial tension, as tobacco, lead
or hard work, or anything that tends to cause arterial disease, as
alcohol or syphilis, is often the cause of this lesion.
At times the edges of the valves may grow together from ulcerative
inflammation, and the lumen thus be diminished in size; or
projecting vegetations may interfere with the opening of the valve
and with the flow of blood. With such narrowing the left ventricle
more or less rapidly hypertrophies to overcome its increased work.
The murmur caused by this lesion is a systolic one, either
accentuated in the second intercostal space at the right of the
sternum, or perhaps heard loudest just to the left of the sternum in
this region. The murmur is also transmitted up the arteries into the
neck, and may at times be heard in the subclavian arteries. It may
also be transmitted downward over the heart. The pulse is slow, the
apex of the rise of the sphymographic arterial tracing is more or
less sustained and rounded, and the rise is much less than normal.
If this lesion occurs in old age, there is general arterial disease
present, and the tension and compressibility of the arteries vary,
depending on how much they are hardened. The disturbed circulation
is evidenced by imperfect peripheral circulation and capillary
sluggishly, with at times pendent edema of the feet and ankles, but,
perhaps, little congestion of the lungs. The left ventricle being
sufficient, there is no damming back through the left auricle to the
lungs. The left ventricle may, however, become weakened, either by
some sudden strain or by a chronic myocarditis, and relative
insufficiency of the mitral valve may occur. The subsequent symptoms
are typically those of loss of compensation.
This lesion may allow a patient to live for years, provided no other
serious disturbance of the heart occurs, such as myocarditis or
coronary disease; but sooner or later, with the failing force of the
blood flow and the lessened aortic pressure, slight attacks of
anemia of the brain occur, causing syncope or fainting. Also, sooner
or later these patients have little cardiac pains. They begin to
"sense" their hearts. There may not be actual anginas, but a little
feeling of discomfort, with perhaps pains shooting up into the neck,
or a feeling of pressure under the sternum. Little excitements or
overexertions are likely to make the heart attempt to contract more
rapidly than it is able to drive the blood through the narrowed
orifice, and this alone causes cardiac discomfort and the feeling of
It is essential, then, that these patients should not hasten and
should not become excited; and any drug or stimulant which would
cause cardiac excitement is bad for them. On the other hand, these
are the very patients in whom, sometimes, alcohol in small doses may
be advisable, especially if the patient is old; and a dose of
alcohol used medicinally when an attack of cardiac disturbance is
present is good treatment. The quick dilatation is valuable.
Nitroglycerin will also do good work in these cases, and with high
blood tension may be the only safe drug for the patient to have on
hand. As soon as his attack occurs, with or without real angina
pectoris, let him dissolve in his mouth a nitroglycerin tablet. If
he feels faint, he will feel better the moment he lies down, and in
this instance he may be improved by a cup of coffee, or a dose of
caffein or camphor.
If the left ventricle becomes still weaker and shows signs of
serious weakness, or if there is actual dilatation, the question of
whether or not digitalis should be used is a subject for careful
decision. The left ventricle should not be forced to act too
sturdily against this aortic resistance. Consequently the dose of
digitalis must be small. On the other hand, it frequently happens,
especially in old age, that myocarditis or fatty degeneration has
already occurred before this cardiac weakness develops in the
presence of aortic narrowing, and digitalis may not be indicated at
all. We cannot tell how far degeneration may have gone, however, and
small doses of digitalis used tentatively and carefully, perhaps 5
drops of an active tincture two or three times a day, and then the
drug carefully increased to a little larger dose to see whether
improvement takes place, is the only way to ascertain whether or not
digitalis can be used with advantage. If it increases the cardiac
pain and distress, it should not be used. Strychnin is then the drug
relied on, with such other general medication as is needed, combined
with the coincident administration of nitroglycerin, which may also
be given in conjunction with digitalis, if deemed advisable.
Generally, however, if a heart with aortic stenosis needs
stimulation, the blood pressure is generally none too high, although
there may be arteriosclerosis present. Therefore when nitroglycerin
is indicated to lower blood pressure, digitalis is not usually
indicated; when digitalis is indicated to aid the heart,
nitroglycerin is generally not indicated. These patients must have
high blood pressure to sustain perfect circulation at the base of
Patients who have this lesion should not use tobacco in large
amounts, or sometimes even small amounts, as tobacco raises the
blood pressure and thus puts more work on the left ventricle; in the
second place, if the left ventricle is failing, much tobacco may
hasten its debility. On the other hand, with a failing left
ventricle and a long previous use of tobacco, it is no time to
prohibit its use absolutely. A failing heart and the sudden stoppage
of tobacco may prove a serious combination.
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