MBBS OSCE · Cardiology / General Medicine

OSCE — assessment of severe symptomatic aortic stenosis

An 8-minute OSCE station assessing the candidate's structured bedside assessment of a patient with severe aortic stenosis — recognising the murmur and pulse, grading severity from echocardiography, stating the Class I AVR indication, and applying the SAVR-vs-TAVI age logic with the medical-therapy caveat. Marks for the bedside signs, the severity trio, and the management plan.

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Exam tags

NEET-PGINICET

Brief (to candidate)

A 73-year-old man is referred with nine months of exertional chest tightness and one episode of collapse while climbing stairs. On examination his pulse is 66/min and slow-rising, BP 128/78, and there is a harsh crescendo–decrescendo systolic murmur at the right second intercostal space radiating to the carotids, with a palpable thrill and a soft delayed A2. An echocardiogram shows a calcified aortic valve, AVA 0.7 cm², mean gradient 50 mmHg, peak velocity 4.7 m/s, LVEF 58%. You have 8 minutes to assess him, confirm the bedside findings, grade the severity, state the indication for intervention, and outline the SAVR-vs-TAVI decision and the medical-therapy caveat.

Candidate instructions

  1. Take a focused history (the symptom triad) and examine the cardiovascular system, demonstrating the pulse character and murmur with dynamic manoeuvres.
  2. Grade the severity of AS from the echocardiographic parameters (the trio).
  3. State the indication for AVR and the timing.
  4. Outline the SAVR-vs-TAVI decision by age, and the medical-therapy caveat.

Examiner checklist (mark each domain / 10)

DomainKey actions expected
History / triadElicits angina, syncope/presyncope, exertional dyspnoea; recognises that symptoms make AVR urgent
Bedside signsSlow-rising (parvus et tardus) pulse; crescendo–decrescendo murmur at right 2nd ICS → carotids; thrill; delayed/absent A2, S4. Murmur loudens on squatting, softens on Valsalva (opposite of HOCM)[1]
Severity gradingStates severe high-gradient AS: Vmax ≥ 4.0 m/s or mean gradient ≥ 40 mmHg, with AVA typically ≤ 1.0 cm² (≤ 0.6 cm²/m² indexed) as supporting evidence; names very severe (Vmax ≥ 5.0 m/s or mean ≥ 60 mmHg)[1]
AVR indicationSymptomatic severe high-gradient AS = Class I for AVR; AVR is the only survival-modifying therapy; do not delay[1][10]
SAVR vs TAVIAt 73 (65–80 band): either SAVR or transfemoral TAVI, by anatomy/risk/preference; gated CT for annulus and access; valve-team and shared decision-making (ESC uses 75 as pivot)[1][2]
InvestigationsTTE definitive; gated CT for TAVI planning; ECG (LVH, conduction); consider coronary assessment for combined CABG
Caveats & safety-netNo drug modifies the disease (statins failed — SEAS/ASTRONOMER); avoid excess vasodilators/diuretics in critical AS; balloon valvuloplasty is bridge/palliative only; surveillance echo for asymptomatic disease

Model key actions

  • Assess: confirm the slow-rising pulse, right-2nd-ICS murmur to the carotids, thrill and delayed A2; demonstrate the squat/Valsalva response to exclude HOCM.[1]
  • Grade: severe high-gradient AS (AVA 0.7 cm², mean 50 mmHg, Vmax 4.7 m/s). Symptomatic → Class I indication for AVR; arrange prompt valve-team review.[1]
  • Plan: at 73, either SAVR or transfemoral TAVI after gated CT (annulus/access), risk scoring and shared decision-making; TAVI evidence spans the risk spectrum (PARTNER, SURTAVI, CoreValve, Evolut).[1][2]
  • Counsel: no drug slows the disease (statins failed); treat comorbid hypertension/coronary disease cautiously; avoid destabilising vasodilators/diuresis.[1][10]

Common errors

  • Not examining the pulse — missing the slow-rising (parvus et tardus) character that clinches severe AS.
  • Grading severity from the valve area alone — a small AVA with a low gradient may be low-flow low-gradient or pseudo-severe AS; examiners expect velocity, gradient and area together.
  • Delaying AVR or recommending "watchful waiting" for a symptomatic patient (Class I, urgent).
  • Recommending statins to slow AS — contradicted by SEAS/ASTRONOMER.
  • Confusing the SAVR-vs-TAVI age bands, or treating balloon valvuloplasty as definitive therapy.[1][10]
References3Show
  1. [1]Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary. Journal of the American College of Cardiology, 2021.PMID 33342587
  2. [2]Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. European Heart Journal, 2022.PMID 34453165
  3. [10]Otto CM, Newby DE, Hillis GS Calcific Aortic Stenosis: A Review. JAMA, 2024.PMID 39527048
OSCE — assessment of severe symptomatic aortic stenosis · MBBS OSCE · NeetVellum