胡大一总编按语：
在重视冠状动脉血管病，忽视结构性心脏病（如主动脉瓣狭窄）；重视多排CT，尤其创伤性冠状动脉造影，而忽视物诊基本功的今天，常常对有胸前导联T波深倒置的老年患者盲目进行冠状动脉造影检查，而事先未认真听心脏杂音。更少的医生会学习认真触摸颈动脉充盈情况和注意胸骨右缘第II肋间第二心音的变化。杂音提示主动脉瓣狭窄之存在，颈动脉充盈缓慢与不足，胸骨右缘第II肋间第二心音减弱或消失，表明狭窄程度严重。

Joseph S. Alpert   亚利桑那大学健康科学中心    《美国医学杂志》主编
Case Report and Discussion

    An 89 year old， recently retired， lawyer drives himself to the emergency ward complaining of central chest discomfort and dyspnea that has been occurring off and on for the last two weeks.  It often comes on with exertion， but recently he has had some bouts of chest discomfort at rest that last for a few minutes and then resolve.  At first， he thought the pain might be related to osteoarthritis， a problem he has had for a number of years. Thinking that the pain was related to his spinal degenerative arthritis， he took two pain tablets and fell asleep.  The pain was still occurring off and on but less severe when he awoke several hours later.  He has never carried a diagnosis of arteriosclerotic heart disease but is being treated for hypertension with a diuretic and an beta blocker. He tells you that he has been known to have a murmur for many years.  He thinks his cholesterol is a bit over 200 but his primary care doctor told him that it was “OK for a man his age”. 
His father died in his 70’s of a myocardial infarction.  His mother died of emphysema at age 71.  He is moderately active， playing golf 3-4 times per week， but has recently stopped because he gets chest discomfort and dyspnea every time he plays. He does not follow any specific diet and is slightly chubby. His vital signs on arrival in the emergency room are:  blood pressure 109/55 mmHg; his pulse is 83 bpm; his respiratory rate is 18/min. His physical exam is remarkable for a small volume carotid pulse， normal JVP， a loud， harsh， ejection murmur loudest along the right sternal border and radiating into the neck.  The murmur lasts throughout systole and the second heart sound is not heard. The chest is clear and there is no peripheral edema.  Neurological exam including cognitive function are normal.  His EKG demonstrates sinus rhythm， LVH with diffuse ST-T wave changes.  An echocardiogram demonstrates severe aortic stenosis with a valve area of 0.6 cm2.  

    When I was a medical student 40 years ago， aortic stenosis was almost always the result of rheumatic heart disease.     These days， rheumatic aortic valve disease has almost vanished in the USA.  However， aortic stenosis is still quite common on the wards of our hospitals.  What accounts for this change in valvular heart disease etiology and why is aortic stenosis now so common? 

    The answer to the questions just posed is two fold:  aortic stenosis in 2009 is the result of congenital bicuspid aortic valves and atherosclerotic/calcific aortic valves.  Approximately 1% of all infants born alive in the US have bicuspid aortic valves.  Mechanical stress is distributed abnormally across the two cusps of these bicuspid valves causes them to “wear out” earlier than expected.  Thus， many individuals with bicuspid aortic valves develop clinically important aortic stenosis during late middle life sometime between the 5th and 6th decades.  Atherosclerotic/calcific aortic stenosis， on the other hand， develops at later in life and is a manifestation of diffuse atherosclerosis that commonly affects elderly individuals.  This lesion usually becomes clinically important when the patient is around age 80 or more.  Since these elderly patients often have a number of co-morbid conditions， the presence of aortic stenosis can present the clinician with a number of challenges particularly in the setting of aortic valve replacement.

病例报告及讨论
    一名近期退休的89岁律师在急诊就诊时，主诉近两周时断时续地出现胸部正中不适及呼吸困难。这种症状通常在劳累时出现，但近期休息时也出现过几次胸部不适，持续几分钟后可以自行缓解。起初，患者认为这种胸痛跟他多年来的骨关节炎有关。考虑到疼痛可能与他的退行性脊柱炎有关，患者一般服两片止痛药物后入睡。疼痛仍时断时续的出现，但在患者睡醒几小时后疼痛程度稍轻。患者从未被诊断为动脉硬化性心脏病，但一直服用利尿剂和β受体阻滞剂治疗高血压。患者诉多年来检查身体时一直有心脏杂音存在。患者认为他的胆固醇水平稍高于200 mg/dl，但他的初级保健医生告诉他对于他们这个年纪的人群这是很正常的情况。

    患者的父亲70多岁时死于心肌梗死，母亲71岁时死于肺气肿。患者的活动量适中，每周打3~4次高尔夫，但近期由于每次活动时均出现胸部不适及呼吸困难而不打了。患者没有什么特别的饮食习惯，稍微有一点胖。他在急诊室的生命体征如下：血压109/55 mm Hg；脉搏83 bpm；呼吸频率18次/分。体检发现颈动脉搏动充盈，JVP正常，胸骨右缘可闻及响亮、粗糙的喷射性杂音，并向颈部传导。在全收缩期均可闻及此杂音，第二心音消失。胸部平坦，没有外周性水肿。包括认知功能在内的神经系统查体均正常。EKG检查示窦性心律，左心室肥大伴广泛的ST-T段改变。超声心动图示严重的主动脉狭窄，瓣膜面积为0.6 cm2。

    40多年前当我还是个医学生时，主动脉狭窄通常为风湿性心脏病的一种表现。近年来，风湿性主动脉瓣膜病好像已经在美国绝迹了。但是，主动脉狭窄在我们医院的病房中仍然很常见。是什么原因导致了瓣膜心脏病的病因学改变，以及主动脉狭窄为何如此常见呢？

    这个问题的答案有两个方面：2009年主动脉狭窄常见于先天性二叶主动脉瓣及动脉粥样硬化/钙化性主动脉瓣病。在美国，大约有1%的新生儿出生时为二叶主动脉瓣。机械应力在这种二叶主动脉瓣的分布异常，导致了瓣膜的“磨损”早于预期。所以，大部分二叶主动脉的个体在五、六十岁时出现严重的主动脉狭窄症状。另一方面，动脉粥样硬化/钙化性主动脉瓣狭窄出现的时期更晚，表现为广泛的动脉粥样硬化，常好发于老年人。这种病变通常在患者80岁左右或是更大年纪时具有重要临床意义。由于这一老年人群常存在一些共患病，特别是在行主动脉置换术时，主动脉狭窄的情况对临床医生来说是一个不小的挑战。

Case Report and Discussion
    Since aortic atherosclerosis is exceedingly common in older Americans， it is not surprising that this process affects the aortic valve whose endothelial lining is continuous with that of the aorta itself.  Early atherosclerosis of the aortic valve can be detected during a routine physical exam:  the characteristic early systolic aortic flow (aortic sclerosis) murmur usually heard best along the upper right sternal border should alert the clinician to the fact that this patient has aortic valve atherosclerosis that may eventually become clinically important atherosclerotic/calcific aortic stenosis over a number of years.  Moreover， the presence of this aortic sclerosis murmur signifies that the patient in question also has atherosclerosis of the aorta itself and very likely atherosclerosis of other arteries， for example， the coronary and/or carotid arteries.

    When atherosclerotic/calcific aortic stenosis becomes severe in an elderly patient， the decision for aortic valve replacement is often a difficult one.  These patients frequently have concomitant fixed renal disease， obstructive pulmonary disease， cerebral atrophy， cerebrovascular disease， diabetes mellitus， and peripheral vascular disease.  Age greater than 80 years and the presence of these listed co-morbid conditions increases the risk for mortal or morbid events following aortic valve replacement.  In most surgical series， aortic valve replacement in patients greater than 80 years of age is associated with a mortality rate r