More recently coversyl 8mg overnight delivery, in their longitudinal study involving first episode consumers with schizophrenia and schizoaffective disorder order 8mg coversyl amex, Robinson et al purchase 8 mg coversyl with mastercard. It was additionally found that consumers who 40 discontinued medication twelve months after the first episode had high rates of second and third relapses, despite careful monitoring by a dedicated research treatment team. In summary, non-adherence to antipsychotic medications following discharge from an acute hospitalisation has been described as the single, most significant risk factor for relapse (Compton, 2007). Whilst antipsychotic medication therapy does not prevent symptom relapses, it can extend the intervals between relapses and render psychotic episodes less severe. There is some evidence to suggest that the longer a patient survives without relapse, the lower the risk of relapse becomes, thus, highlighting the long-term benefits associated with adherence (Birchwood & Jackson, 2001). Additionally, if a relapse does occur, despite the beneficial effects of taking medication, it reportedly tends to be milder and can usually be effectively treated by temporarily increasing the dosage of antipsychotic medication (Mueser & Gingerich, 2006). The prevention of multiple relapses and extension of periods between episodes is critical, as not only are relapses distressing, causing significant emotional and psychological damage, but they can also lead to irreversible social consequences and increase the likelihood of symptoms persisting between episodes (Birchwood & Jackson, 2001) Non-adherence amongst people with schizophrenia has also been shown to be significantly associated with increased rate and length of rehospitalisation, increased costs of care as well as increased risk of emergency room visits (Compton, 2007; Lacro et al. In their study which examined the medical histories of 63 consumers who were regularly hospitalised, Weiden and Glazer (1997) reported that the most common reason for hospitalisation was non-adherence, which accounted for 50% of cases. Moreover, with each 41 missed day of medication, the risk of rehospitalisation increases. Rehospitalisation is reportedly four times higher among patients who miss 30 days or more over a year compared to those who take their medication as prescribed (Kozma & Grogg, 2003 cited in Masand & Narasimhan, 2006). Regarding the costs associated with non-adherence, Masand and Narasimhan (2006) point out that not only are the direct, medical costs high, particularly when there are recurrent hospitalisations and ongoing outpatient care is required, but the indirect costs related to disability and unemployment are even greater. Even partial non-adherence can lead to worsening symptoms and an increased risk of relapse and rehospitalisation. Irregular adherence has been associated with approximately a two-fold increase in hospitalisation and a four-fold increase in number of days hospitalised in another study, however (Svarstad, Shireman & Sweeney, 2001). Such data provide further support for the importance of adherence to continuous, maintenance medication schedules. Amongst people with schizophrenia, more specifically, the prevalence of non- 42 adherence with maintenance antipsychotic medications has been reported in the range of 30-50% for oral and 10-15% for depot preparations in early studies (Johnson, 1993; Kane & Borstein, 1985). A more recent French study reported that 30% of inpatients were considered to be non-adherent (Dassa et al. Such figures may be optimistic, however, in the context of several recent studies which have reported non-adherence rates between 40 and 55% (Compton, 2007; Gray, Wykes & Gournay, 2002; Lacro et al. Further complicating the measurement of adherence amongst people with schizophrenia is the fact that rates have been demonstrated to change over time. In an attempt to overcome potential social desirability bias amongst consumers’ self-reports of adherence, Moritz et al. A recent review of the literature relating to adherence amongst people with schizophrenia suggested that if a high standard of ideal adherence is applied, less than 25% of consumers will meet the criterion (Mitchell, 2007). It is frequently stated that adherence in psychiatric populations is no better or worse than in other medical settings (e. Following a review of previous studies of treatment adherence, Cramer and Rosenheck (1998) concluded that an average of 58% of patients receiving antipsychotics were adherent with medication compared to 76% of patients prescribed medication for physical disorders, with inter-individual variation in adherence behaviour evident for both groups. In order to explain the high rates of non-adherence amongst people with schizophrenia and people with chronic physical illnesses alike, Baldessarini (1994) proposed that the acceptance of prolonged medical treatment may be fundamentally inconsistent with human nature. True rates of non-adherence are difficult to quantify in schizophrenia for methodological reasons, thus, accounting for the significant variation in rates reported. Some of the ways that adherence amongst people with schizophrenia has been measured include reliance on patient or relative self- report, prescription renewals, pill counts, using electronic adherence monitors on pill bottle caps, saliva and urine screens and steady-state serum determinations (Battaglia, 2001; Fenton et al. None of these methods provide a completely reliable indication of adherence, however (Masand & Narasimhan, 2006). Statistically evaluating medication adherence is additionally complicated by varying definitions of adherence. As Battaglia (2001) points out, medication adherence is rarely an all-or-none phenomenon as it can include errors of omission, mistakes in dosage and time taken as well as taking medications not currently prescribed. Variations in clinical setting, study duration and characteristics of the study population may further account for differences in the reported prevalence of adherence (Mortiz et al. Thus, several attempts have been made to assess which specific factors influence adherence to antipsychotic medications amongst people with schizophrenia, with varying results. Studies that have investigated adherence to medications amongst mental health consumers vary in their definitions of adherence, methodology used and study populations, rendering interpretation of results across studies difficult and accounting for differences in findings (Julius, Novitsky & Dubin, 2009). The following section summarises a selection of quantitative research on predictors of medication adherence. A summary of the extant qualitative research related to adherence amongst people with schizophrenia is then presented. Of note, there has been significantly less qualitative research conducted in the topic area. Due to the limited amount of qualitative research directly related to adherence to medication amongst people with schizophrenia, results from some studies that explored adherence amongst psychiatric populations and chronically ill consumers more generally have also been summarised. It was developed as part of a longitudinal study of antipsychotic non-adherence and was administered to 115 outpatients with schizophrenia. Part two contains items pertaining to no perceived daily benefit, negative relationship with clinician, negative relationship with therapist, practitioner opposed to medication, family/friend opposed to medication, access to treatment problems, embarrassment or stigma over medication or illness, financial obstacles, substance abuse, denial of illness, 46 medication currently unnecessary, distressed by side effects and desires rehospitalisation (Weiden et al. In relation to illness characteristics, the studies reviewed yielded no relationship between adherence and age at onset and duration of illness, age at first hospitalisation and premorbid functioning. Of the eight studies reviewed which assessed the relationship between illness symptom severity or global functioning and inpatient medication refusal or future outpatient non-adherence, one reported an association between more severe psychopathology including disorganisation, hostility and suspiciousness and inpatient drug refusal and five studies linked symptom severity at or after discharge to poor outpatient adherence or poor attitudes towards medication. One study also linked the grandiosity score on the Brief Psychiatric Rating Scale to poor adherence. Whilst the authors did not find support for an association between memory or cognition on adherence, they acknowledged that a significant percentage of outpatients attributed non-adherence to forgetting or indicated that 47 reminders to take their medication would be of assistance. Poor insight, as measured by a variety of self-report instruments assessing illness awareness, was consistently linked with non-adherence. Three studies showed an association between poor insight at admission or during hospitalisation and non-adherence in inpatient settings. Four studies linked lack of insight at admission, discharge or post-discharge assessment to poor outpatient adherence. Poor insight, negative attitude or subjective response to medication, substance abuse, shorter illness duration, inadequate hospital discharge planning and poor therapeutic alliance were the risk factors found to be most consistently associated with non-adherence. There was an absence of support for relationships between illness-related factors, including neuro-cognitive impairment, severity of positive symptoms and the presence of mood symptoms and adherence. Furthermore, the severity of medication side effects, dose of medication, route of medication administration and family involvement were not found to be consistent predictors of non- adherence. However, a limitation of the review was that many of the studies included were retrospective, cross-sectional and conducted prior to the introduction of atypical antipsychotic medications.
Distorted means that your thinking doesn’t accurately reﬂect buy generic coversyl 8 mg online, predict purchase cheap coversyl line, or describe what’s going on purchase coversyl on line. Perhaps your mind ﬁlled with thoughts of dread and images of someone breaking into your house. For example, we have a dog we think is truly beautiful, but most of our friends and neighbors think he’s a peculiar-looking mutt. No doubt our perception is slightly ﬂawed; it’s understandable because we love our dog, but it’s distorted nevertheless. The three types of reality scramblers are: The Information Reality Scramblers The Self-Judging Reality Scramblers The Self-Blame Reality Scramblers Although this chapter makes distinctions among various types of reality scramblers, in real- ity, scramblers often overlap or exist in groups. To put it another way, a single thought can involve several Information Reality Scramblers as well as scramblers involving self-judging and self-blame. The Information Reality Scramblers Information Reality Scramblers warp your perceptions of your world and events occurring around you; they distort how you think about what’s really happening. You may not know that Information Reality Scramblers affect your thinking, but if you give it a little thought, you’re likely to see that they do. For example, suppose a depressed man receives a mediocre per- formance review at work. He’s likely to enlarge this event and turn it into a complete catastrophe by assuming that he’s totally worthless as a person. Without the scrambler, the reality is simply that his perform- ance was considered average even though he would have preferred a better rating. This exercise shows you all the various ways that Information Reality Scramblers can affect your thinking and ultimately the way you feel. Read the description of each type of Information Reality Scrambler and the accom- panying examples in Worksheet 5-1. Think about when your thoughts might have been inﬂuenced by the Information Reality Scrambler. Reﬂect and write down any examples of speciﬁc thoughts that you’ve had which might be distorted by an Information Reality Scrambler. If you can’t think of an example for each type of Information Reality Scrambler, that’s okay. We give you more exercises for seeing how they do their work later in this chapter. Enlarging and shrinking: Your mind magniﬁes the awfulness of unpleasant events and minimizes the value and importance of anything positive about yourself, your world, or your future. Filtering: Your mind searches for dismal, dark, or frightening data while screening out more positive information. For example, suppose you receive a job evaluation that rates you highly on most areas but contains one average rating. You proceed to focus exclusively on the average rating and conclude that the evaluation was mediocre. Seeing in black-or-white, all-or-none terms: Your mind views events and your character as either black or white, with no shades of gray. Or when teenagers notice blem- ishes on their faces, they often conclude that they look totally horrible. The problem with such polarized thinking is that it sets you up for inevitable failure, disappoint- ment, and self-abuse. Dismissing evidence: Your mind discards evidence that may contradict its negative thoughts. For example, suppose you’re preparing a speech and have the thought that when it comes time to give the speech, you’ll be so scared that you won’t be able to talk. Your mind automatically dismisses the fact that you’ve given numerous speeches before and have never been so afraid you couldn’t talk. Overgeneralizing: You look at a single, unpleasant occurrence and decide that this event represents a general, unrelenting trend. For example, a wife tells her husband that she’s furious because he’s always late, but in reality he’s late only about 10 percent of the time. Mind reading: You assume that you know what others are thinking without checking it out. Thus, when your boss walks by you without saying hello, you automatically think, “She’s really angry with me; I must have messed something up. For example, if you feel guilty, you conclude that you must have done something wrong. Or if you don’t feel like working on your depression, you assume that means you’re unable to. And if you’re afraid of something, it must be dangerous merely because you fear it. For example, you have an argument with your partner and believe that he or she will certainly leave you. Or, you avoid driving on the freeway because you’re convinced that you’ll get in an accident. Before you get to work on your own Thought Tracker, see what Bradford (see Worksheet 5-2) and Sheila (see Worksheet 5-3) discover when they track their thoughts and analyze them for reality scramblers. Worksheet 5-2 Bradford’s Thought Tracker Feelings and Sensations Corresponding Events Thoughts/ Information Reality (Rated 1–100) Interpretations Scramblers Despondent (70), My boss said we I hate this job. The Enlarging, mind anxious (65); had to increase boss must hate reading, seeing tightness in my our productivity. I can’t white terms, possibly meet overgeneralizing, this standard; unreliable what then? The real Things like this and-white terms, fatigue estate agent said never work out dismissing we could get just for me. Chapter 5: Untangling Twisted Thinking 61 Worksheet 5-3 Sheila’s Thought Tracker Feelings and Sensations Corresponding Events Thoughts/ Information Reality (Rated 1–100) Interpretations Scramblers Panic (90); racing Jason’s 20 He’s never this Emotional pulse, shaky, nausea minutes late late; something reasoning, coming home horrible must unreliable from school. Nervous (70); Getting the No one is going Unreliable queasy stomach house ready for to show up. Now that you’ve seen a couple examples of Information Reality Scramblers at work, it’s time to take a challenge and see if you can pick out Information Reality Scramblers in differ- ent situations. Worksheet 5-4 presents an incomplete Thought Tracker with samples from an assortment of people and events. Review the feelings and sensations, events, and thoughts and interpretations of those events provided, and then ﬁll in the Information Reality Scramblers that you believe apply. Worksheet 5-4 Thought Tracker Information Reality Scrambler Practice Scenario Feelings and Sensations Corresponding Thoughts/ Information (Rated 1–100) Events Interpretations Reality Scramblers 1 Miserable (65), My wife It’s true. I’ll get more money, but the only reason I got the job is because no one else wanted it.
The literature is searched to determine the probability of an adverse outcome related to the medical condition generic coversyl 8 mg visa, in this case incarceration and strangulation purchase 8 mg coversyl mastercard. Edwards’ prognosis purchase coversyl uk, apply the following four criteria: • Determine the characteristics of the patients in the study (deﬁned, representative sample assembled at a common point in the course of their disease). Step 3: Deciding on the Best Therapy Step 3 in the algorithm is deciding on the best therapy for your patient. The essential element in framing the question about best therapy focuses on what interventions (cause/prognostic factor/ treatment/etc. This process is critical to the development of a treatment recommendation that is individualized for each patient. Edwards, surgery will become necessary; the natural history of a hernia is that it becomes larger with the passage of time, does not resolve spontaneously, and can result in intestinal obstruction or stran- gulation. In this speciﬁc example, it is difﬁcult to identify published studies in which patients with inguinal hernia were randomized prospectively to operative versus nonoperative therapy. Historically, however, prior to the common practice of elective repair, hernias were known as the most common cause of intestinal obstruction. Creating an evidence-based medicine question Element Patient Intervention Comparison Outcome of problem intervention clinical interest Question Male, L Open Laparoscopic Optimal component inguinal operative procedure operative hernia procedure procedure for reducing inguinal hernia experts). Unless a patient is so debilitated that his life expectancy is very short or his comorbid conditions are so severe that operative risks are considered to be unacceptable, one should consider prophylactic repair. Hernia surgery poses an acceptable level of risk when compared to the high likelihood of intestinal obstruction or strangulation without elective preventive surgery. A literature search also reveals that the risk of hernia strangulation is thought to be greatest in the period soon after initial presentation. The literature identiﬁes three treatment options: observation with reevaluation in 2 weeks, immediate surgery, and elective surgery 6 months hence. Reducing the risk of the potential complications of hernias (incarceration and strangulation) is best achieved through minimizing the time until surgery. Edwards’ treatment plan develops as follows: • Preferred treatment is elective surgery, scheduled as soon as possi- ble, with biweekly follow-up by the primary care physician during the interim and patient education related to the signs and symptoms of an incarcerated or strangulated hernia. The essential element is specifying comparison “interventions,” for example, compar- ing open and laparoscopic techniques. The evidence-based question about estimating best therapy becomes: For a male patient with a simple left inguinal hernia, is a laparoscopic or open procedure the preferred approach? Jones, in Surgery: Basic Science and Clinical Evidence, cited above, for the techniques to repair primary inguinal hernias. Creating an evidence-based medicine question Element Patient Intervention Comparison Outcome of problem intervention clinical interest Question Male with Laparoscopic Open Adverse effects, component L inguinal time to recovery hernia In reviewing the studies for treatment, there are two major questions to be answered: Was there randomized assignment of patients to experimental conditions and were they analyzed in the groups to which they were assigned? Was the attrition rate reported and were all patients who entered the study accounted for at the conclusion of the study? In a quick search of Cochrane’s database, you ﬁnd two prospective, nonrandomized trials describing the outcomes of using an open approach (the Lichtenstein approach) to repair primary inguinal hernias: one by Kark et al5 reporting a series of 3175 and one by Lichtenstein’s group6 reporting 4000 repairs. With the use of the open Lichtenstein approach, the rate of recurrence varied from 0. Step 4: Determining Harm In reviewing studies of negative outcome, two basic questions must be answered: 1. And, if so, was the particular intervention responsible for the nega- tive outcome in the speciﬁc patient? The focus of the question is obtaining data about the adverse outcomes associated with the use of open versus laparo- 9 scopic operative techniques. After reviewing the information, you conclude that the major difference between the two laparoscopic procedures versus the open Lichtenstein procedure is that, although laparoscopic procedures cost signiﬁcantly more, laparoscopic procedures appear to allow patients to return to work more quickly. Step 5: Providing Care of the Highest Quality In the ﬁnal step in the algorithm, the element that is emphasized is assuring that the clinical decision making of the physician optimized the outcome for Mr. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. Inguinal hernia repair: totally pre-peritoneal laparoscopic approach versus Stoppa operation, randomized trial: 100 cases. Early outcome after open versus extraperitoneal endoscopic tension-free hernioplasty: a randomized clinical trial. A randomized, controlled, clinical study of laparoscopic vs open tension-free inguinal hernia repair. Edwards so that he can be a participant in his care and give informed consent to the treatment of his choice. The patient’s most important concern is that he is able to return to work in the shortest time possible. Given the information about the risks and beneﬁts inherent to each procedure, he elects to have the laparoscopic hernia repair. Summary Evidence-based medicine provides a systematic approach to ensuring the delivery of the highest quality of care possible to patients. It draws on the best evidence available to inform the practice of skilled and experienced clinicians. The quality of the evidence ranges from useful but potentially biased single-case studies to randomized clinical trials that meet the strictest standards of scientiﬁc rigor. Additional useful evidence can be obtained from meta-analyses, outcome studies, and practice guidelines. Evidence-based medicine has ﬁve core tenets for practicing medicine: • Clinical decision making should be based on the best available scientiﬁc evidence. The evidence-based medicine algorithm for delivering quality patient care contains ﬁve clinical objectives: 1. Providing care of the highest quality Application of the ﬁve core tenets of evidence-based medicine to the ﬁve clinical objectives promotes the optimal practice of surgery. Three “pearls” to keep in mind: • Clinical wisdom is invaluable but never above question. Practicing Evidence-Based Surgery 41 • Browser for current practice guidelines • A site to compare guidelines • Practice resources http://nlm. The contents include the following: • Health topics—information on conditions, diseases, and wellness, and a medical encyclopedia • Drug information • Dictionaries • Other resources: • Link to Clintrials. Cases Case 1 A 67-year-old man with obstructing esophageal cancer presents for consideration of surgical therapy. He has lost 25 pounds (15% of normal body weight) over the past 4 months, is unable to swallow anything except liquids, and has near-complete loss of appetite. He has no other past history of signiﬁcance and takes medications only for hyperten- sion. Case 2 A previously healthy 27-year-old woman is the restrained driver in a head-on collision. Nutrition Support in the Surgery Patient 43 received 4000mL of crystalloid solutions intraoperatively.
Profoundly cyanotic infants may require the creation of adequate blood supply to the pulmonary circulation discount coversyl 8 mg amex. A modiﬁcation of the classic Blalock-Taussig shunt (subclavian artery to pulmonary artery) is per- formed and can be closed when the deﬁnitive procedure is performed buy coversyl 8 mg free shipping. The presence of profound pulmonary overcirculation discount coversyl master card, which may occur with a large ventricular septal defect or aortopulmonary window, may require pulmonary artery banding to restrict pulmonary blood ﬂow. The dominant approach to many of these lesions now is one of total correction in infancy rather than palliation with later correction. Lesions that lead to overcirculation of the pulmonary vasculature must be corrected early in life or palliated before irreversible pulmonary hypertension develops. Repairs of atrial septal defects usually can be delayed until a child reaches 3 or 4 years of age and can be corrected before he/she begins school. The risk of endocarditis is increased sig- niﬁcantly in these patients as well as in older patients with a patent ductus. Results With increasing reﬁnements in the techniques of pediatric cardiac surgery, the operative mortality for many of these procedures has dropped dramatically with improved long-term survival. It is no longer uncommon to see adults who have undergone corrective surgery as children parenting their own children. Heart Murmurs: Congenital Heart Disease 263 Summary A heart murmur present in a child or an infant with signs and symp- toms of congestive heart failure or cyanosis is indicative of a signiﬁ- cant mechanical lesion within the heart. A relatively simple method of classiﬁcation of these potentially complex lesions is based on the pre- senting symptom of the patient, either congestive heart failure or cyanosis. To understand the potential signiﬁcance of a heart murmur in the absence of symptoms. To recognize the need for anticoagulants in patients following valvular heart surgery. Cases Case 1 A 55-year-old man presents to your ofﬁce complaining of fatigue and shortness of breath after playing one set of tennis. She had the same feeling of “indigestion” a few days ago that lasted 3 to 4 hours. She has been in excellent health prior to this time and denies any prior cardiac or respiratory problems. Heart Murmurs: Acquired Heart Disease 265 Introduction Heart murmurs can be found at any age. Chapter 14 described lesions that are congenital in nature and likely to cause murmurs in the neonate or child. This chapter discusses heart murmurs related to acquired heart disease that become apparent in the adult population. Acquired disease of the heart valves can be a major clinical problem frequently requiring surgical correction. Of the four cardiac valves, the aortic and mitral valves most commonly are involved. Structural changes in the tricuspid valve can occur, but the leading causes of tricuspid valvular disease are changes secondary to left-sided heart failure and pulmonary hypertension secondary to valvular disease of the aortic or mitral valve. Onset of symptoms can be quite sudden (Case 2) when attribut- able to acute changes in structural anatomy of the valve (endocardi- tis, aortic dissection, and ruptured papillary muscle or chordae tendinae). More often, patients present with progressive symptoms, although an acute episode of heart failure or pulmonary edema may draw attention to the disease process. In either situation, proper workup and appropriate medical and surgical therapy are crucial to the long- and short-term well-being of the patient. They come within greatest approximation at the noncoronary sinus of the aortic valve: the ante- rior leaﬂet of the mitral valve can be viewed, at the time of aortic valve surgery, as lying just below the noncoronary sinus. The normal aortic valve is a three-leaﬂet structure consisting of the 2 left, right, and noncoronary leaﬂets. Although variations can occur, the right coronary artery arises from the right 1 The Society of Thoracic Surgeons National Adult Cardiac Surgery Database, 1999. Vol- untary registry of results from more than 500 participating cardiac surgery programs nationwide. Anatomy of the cardiac valves, viewed as transverse section at the level of the base of the heart. The left coronary artery arises from the left sinus and is located relatively posterior. The noncoronary sinus is toward the right side of the aortic root and lies closest to the surgeon when viewed in the operating room. The bundle of His lies just below the aortic annulus in the right coronary sinus adjacent to its junction with the noncoronary sinus. This relationship explains the potential for the development of heart block related to aortic valvular disease or to complications of aortic valve replacement. Often, increasing heart block is an indication of a pro- gressive aortic root abscess in the presence of endocarditis, even if the patient appears to be improving otherwise, and is an indication for urgent surgery. In cross section, it looks like a parachute with the larger anterior leaﬂet and smaller posterior leaﬂets tethered to the papillary muscles and mitral valve annulus by the chordae tendinae. Disruption or stretching of the chordae or papil- lary muscle results in mitral insufﬁciency due to the loss of the teth- ering mechanisms, which then permits prolapse of the valve leaﬂet back into the atrium. The right-sided heart valves are comparable to those on the left side but less prone to isolated structural problems. The pulmonic valve is a trileaﬂet valve similar in appearance to the aortic valve. The tricuspid valve has three leaﬂets of unequal size with a supporting apparatus similar to the mitral valve. Signiﬁcant pulmonary hypertension can lead to secondary dilatation of the tricuspid annulus and result in tricuspid insufﬁciency. Differential Diagnosis In any adult patient presenting with new-onset congestive heart failure, exercise intolerance (Case 1), cardiogenic shock (Case 2), increasing fatigue, or angina, a signiﬁcant valve problem must be considered. Next, it must be determined if a heart valve abnormality is, in fact, the cause of the murmur. Other causes do exist, such as congen- ital heart disease that was not recognized during childhood or an acquired ventricular defect following a myocardial infarction. The pres- ence of a heart murmur can signify a benign or malignant tumor of the heart. Careful history and physical examination will determine the clinical signiﬁcance of the murmur. Mitral stenosis Valvular Rheumatic disease Nonrheumatic disease Infective endocarditis Congenital mitral stenosis Single papillary muscle (parachute valve) Mitral annual calciﬁcation Supravalvular Myxoma Left atrial thrombus Mitral insufﬁciency Valvular Rheumatic fever Endocarditis Systemic lupus erythematosis Congenital Cleft leaﬂet (isolated) Endocardial cushion defect Connective tissue disorders Annular Degeneration Dilation Subvalvular Chordae tendinae Endocarditis Myocardial infarction Connective tissue disorder Rheumatic disease Papillary muscle Dysfunction or rupture Ischemia or infarction Endocarditis Inﬂammatory disorder Malalignment Left ventricular dilation Cardiomyopathy Aortic stenosisa Acquired Rheumatic disease Degenerative (ﬁbrocalciﬁc) disease Tricuspid valve Congenital bicuspid valve Infective endocarditis Congenital Tricuspid valve with commissural fusion Unicuspid unicommissural valve Hypoplastic annulus Aortic insufﬁciency Valvular Rheumatic disease Congenital Endocarditis Connective tissue disorder (Marfan’s) Annular Connective tissue disorders (Marfan’s) Aortic dissection Hypertension Inﬂammatory disease (e. The etiology of aortic stenosis is multi- factorial and often can be inferred by the age of onset of symptoms.