#118 REPOST: Aortic stenosis

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All you need to do to sign up is go to pacesahead.com And I advertise for these two sponsors because I genuinely believe that combined they essentially guarantee you'll get that all important parts in Paces. So use the discount code Pre Paces 15 at Quesimed.com and sign up today! Hi there listers, it's Dr Sam Williams here and I've got to be honest with you. I've had a busy few weeks. In the last month I have moved house, I've re-certified my ALS. I've sat and thankfully passed the European exam of core cardiology, which is sort of like an exit exam for cardiologists. I've been slinging portfolio tickets like there's no tomorrow in preparation for ALCP and there's one big loose end left to tie up. I'm getting married and so I've decided for the next month I'm taking a break on the podcast to allow me to focus on that. So for the next two episodes of the podcast I'll be focusing on making my special day as it should be and in lieu of a brand new episode for you guys, I will be reliving a couple of my favourite episodes of the podcast. And we're going back to where we're all began with Dr Steve Dorman, consultant cardiologist, Instructural Intervention, where he and I discussed aortic stenosis. And I'm pleased to say listeners that there is very little that is out of date in this episode. It's one of my absolute favourites and I host these so much for setting the highest standards I've tried to keep up in the rest of the podcast. So I hope you enjoy this repost listeners and it feels mad to say this truly. But in two weeks time I'll be happily married and enjoying a mini-moon in Cornwall. So keep your ears out for another repost in two weeks and after that we will recommence regular programming If any of you want to buy a coffee on the big day, it's Thursday, the 31st of July. I love you all, I'll catch you very soon but for now I'll leave you with a version of me from 2021. Welcome to the pre-paces podcast with me, Dr Sam Williams. For this episode we could not have anyone better to join us to discuss this week's topic of aortic stenosis. I was joined by Dr Steve Dorman, interventional cardiology consultant at the Bristol Heart Institute who sub-specialises in transcaffeter aortic valve implantation or tavvy. We go through the correct approach to a paces cardiology station and what signs to look out for in a patient with aortic stenosis. Steve and I discuss some answers to the common examiner questions and after that I introduce the new feature quiz the consultant where our bosses take on a quick fire quiz on the topic of their own choosing with the caveat being it can't be related to medicine. Don't forget to like and follow us on social media at pre-pacespodcast.com Subscribe wherever you get your podcasts and most importantly of all, enjoy the show. Welcome to the pre-paces podcast. The only podcast that gives you free open access to medical education, you can digest on your way to work in the gym or wherever you're choosing to revise for the MRCP Paces exam. Today's episode is a dive into a station you know features in Paces time after time, aortic stenosis. I think it would be fair to say that while I guess doesn't know about aortic stenosis isn't worth knowing. To help us navigate through aortic stenosis we are joined by Dr Steve Dorman. Steve is an interventional cardiology consultant at the Bristol Heart Institute who plays a leading role in delivering the transcaffeter aortic valve implantation or tavi service within the trust. I think it would be fair to say that we couldn't have anyone better joining to discuss the topic of aortic stenosis. So Steve, how do you describe your involvement in treating patients with aortic stenosis? Thanks Anne. So I started off as a stent doctor and tavi's really sort of exploded in the last five years and so increasingly probably 70% of my time is spent doing aortic stenosis. We've now got 24 randomized controlled trials from the low risk through to the inoperable that all demonstrating that tavi is a very viable option. So there's going to be a real explosion in the use of tavi for aortic valve replacement in the next few years. So I'm the leader of the tavi service in Bristol and yeah I really enjoy doing it because it's a very satisfying procedure to do because the patients generally feel better and live longer afterwards. Perfect. So as I said we've got an esteemed expert joining us to talk about his area of specialism and not only will Dr Dorman be giving us an expert's view of aortic stenosis. He will also be the first consultant to act as a guinea pig on our new feature, quiz the consultant. This is the quiz where our bosses take on a number of questions on a specialist subject of their own choosing with the caveat that it can't be anything to do with medicine. So Steve, before we jump into aortic stenosis, what have you named as your specialist subject and why? So this is a bit of a tricky one because I really don't have a social life because I've spent my life in the hospital. Excepting the light you've forced me to name one. I've named foiling foils as the technology to be quizzed on. And this is foils in the context of wind surfing and surfing. Yes, foils in the context of watercraft but particularly wind surfing, kite surfing. This was something which is completely new to me and it was a real blast researching for the quiz. So we've got that coming up towards the end of the show. And since we've introduced our guest, let's jump into this week's topic of aortic stenosis. So Steve, just a set the scene, the cardiology station is a purely examination station which is most likely the place where aortic stenosis is going to come up. So no history is available apart from a very brief one line as a lead into the examination. The candidates will get six minutes to examine the patients and ascertain the patient has aortic stenosis before having four minutes of questions from the examiner. Now we know that there are a number of congenital syndromes which can be associated with forms of aortic stenosis but we're very much focusing on the conventional aortic stenosis that we tend to see more in hospital than the congenital forms. With regard to the key aspects of examination. I thought we could cover this either in one or two ways which is either we go through the examination chronologically but I felt it would be better for us to cover the most pertinent findings of an examination as you find them. And the clear and most obvious sign that you have a patient with aortic stenosis would be the murmur. So Steve, what does the characteristic murmur of aortic stenosis sound like? So I think the murmur is the one thing that you will pick up on and does sound characteristic of AS. It's quite hard to describe. It's a sort of "whu" and the longer it is late peaking the more severe it is. And it's one of the few murmurs that there is a good agreement between cardiologists that they can use to grade the severity. Now the one exception to that is as it becomes critical ironically the murmur gets quieter. So now you should be seeing less and less critical AS in the Paces exam because I would hope that they would be operated on or have a taboo. So it is a reasonably reliable murmur. It's a crescendo, decrescendo murmur. And I'm afraid there's no substitute for just hearing quite a few of them but it definitely sounds different from the mitral regurgers and murmur. I think the clue you'll get first is from feeling the pulse. We'll go on to the pulse in a second. If the pulse is slow rising that's giving you a clue that you're going to be hearing a crescendo, decrescendo murmur. Like you said, it's critically important to just listen to as many murmurs as you possibly can to be able to differentiate between that. As you just said, you're actually most of the time feeling the pulse before you go on to listen to the chest. So in these patients the way you're doing, you are listening to the patients that have aortic stenosis, actually getting a reliable instinct for what a slow rising pulse feels like will then make you prick your ears up and think this could be aortic stenosis. So Steve, you mentioned about the slow rising pulse. So that can be, as we've said, it's difficult to perfectly describe it. And obviously the experience of palpating the pulse and getting an instinct for how it feels. But trying you are the most best, how would you describe that slow rising pulse? Yeah, again, it's got to be experienced rather than just dried, but slow and late, I guess, are the features that you feel of it. You expect that pulse to be coming in sooner than it does. And when you feel anything, all that's a bit late. And it's just more prominent than you expected to be. So as soon as you've got that and you've got a systolic murmur, then your thinking is this A.A.? The other thing to note about the murmur itself is obviously the radiation. You can hear the murmur throughout the chest the most of the time. We were talking just before the recording about the galavard in phenomenon, which it was something maybe wasn't, it was familiar with. For me, it was very much during my Paces Revision, get out of jail free card for something which is a murmur which is heard throughout the chest. And if you are not sure, although you can hear it maybe at the apex, you can hear it in the axilla, often just to cover your bases, you can say it's the galavard in phenomenon, which is the radiation of a murmur of a eeltics stenosis across the chest into the apex to mimic something like a mitral regurgitation or other murmurs. The other thing which is characteristic of eeltics stenosis is radiation to the carotids. You agree with that? Yeah, I think it is. I think if I'm being honest, I think you would expect somebody to be able to pick up a systolic murmur. You'd ideally be asked them to be able to characterise it. But the reality is that all these things do play second fiddle to further investigations. So in some ways it's a game, it's like the driving test, you have to do mirror signal maneuver, you have to go through it. So listen to what Sam has to say. But realistically, I would expect somebody to get a systolic murmur. I'd like them to tell me it was radiating up, radiating up to the carotids. But the reality is you can hear it in lots of different places, depending on the shape of some of his chest. And I think the other point which will come on to later in the episode as well is covering your bases in the differential diagnoses, which it could also be. Other potential signs that you could find might be a complication as such of aeltic stenosis. And these are seen relatively frequently on the cardiology wards, at least here in the Bristol Heart Institute, where we do do a lot of tavi. And these would be relatively common signs of simple heart failure, really. So whenever you get a murmur in places, your next question is over at current decomposition, clinically on examination, yet a dimmer bibasal crackles raise JVP, most of the aeltics, the to stable for paces probably won't have active decomposition. So the chest will probably be clear that the JVP won't be up and there won't be a dimmer. But there may be. So I just, I would associate the question, the examiner is always going to say, is the evidence of active decomposition or I would be saying, it's a poor prognostic marker. So you always want to just have that little triad, just have ticked off in your brain. But most of the time the aeltics, stenotics are not going to present to a paces scenario with decomposition, because frankly we should be treating them more quickly. Absolutely. The last couple of signs, which potentially you could pick up, but again, they're not going to be the, the things which the examiner is expecting to come out with first, although they may lend credence to your conclusion of aeltics stenosis. And these, a lot of these actually are signs found on palpation. So, for example, something like a displaced apex beat, which might be indicative of lefentricular hypertrophy as a result of longstanding aeltics stenosis or a lefentricular heave or a peepable thrill, which although we do see a lot of tabby patients, they come around quite infrequently. Yeah. And if I'm honest here, I would, if you think you've picked it up, you could give a soft sign to the examiner, but no one's going to fail you for, you're not going to be diagnosing aeltics stenosis on the basis of any of the palpation symptoms. Perfect. And then again, this is a very soft sign, which obviously has many, many different causes, but contract-tival pala as a sign of anemia is possible. Obviously, there are many, many causes of anemia far beyond the scope of this podcast episode. But in a patient with aeltics stenosis, there are a number of reasons why a patient may be anemic. So obviously, this might come into the questions maybe at the end. But Steve, you want to tell us why are aeltics stenosis particularly prone to developing anemia? I think if somebody spotted anemia with aeltics stenosis, I would be very impressed. And actually, it is a real thing that we see. You get the anemia of chronic disease, first of all, because most of our patients are elderly. But the thing that we see more often is angiodesplasia. And you can have patients presenting with hemoglobin of 6 or 7 with critical aeltics stenosis, severe aeltics stenosis, and it's not that uncommon. So actually, the associated syndrome is very real. You're probably not going to see it in a patient's exam, but it would be nice to say there's no evidence of anemia suggesting that there is not an overt problem with a GI bleed or with angiodesplasia and aeltics syndrome. And is there any association between or have you found any association between the severity of aeltics stenosis and the occurrence of aeltics or angiodesplasia? I mean, I don't know, we probably do about 220 tavers a year. And I would say that every year we get four or five good-going aeltics syndrome that we see in that number who've dropped their hemoglobin to five. And then what we do find is actually there is a relatively good improvement. They don't require transfusion afterwards. I can't say I fully understand why and you can't promise the patient that that's the case. But we do see people who are entirely transfusion dependent ceasing to need it. It's almost always an association with proper severe high-end aeltics stenosis. It's not an association with low grade, you know, low grade peak radians. One of the things which comes up in books quite often, or at least in some of the revision resources, is hemolysis through a native aeltic valve. And Steve, you told me before that this is vanishingly rare and it is very much a textbook note. We see in context of valves that we put in the heart. So we can see hemolysis on a tavi valve on a prosthetic aeltic valve. We just don't see it very commonly in the context of native valves. I suppose if you've got a severely degenerated one with endocarditis associated with it, then suddenly you've got a bit more of a milieu. But it's vanishingly rare to see hemolysis in combination with a native aeltic valve. So just to recap very quickly. So we've gone through the characteristic murmur of aeltics the noces being a crescendo, decrescendo murmur. Obviously you're hearing it loudest at the aeltic area. And one other thing which is probably worth noting, or at least worth noting in your description of the murmur, is during your maneuvers to accentuate the murmur, it should be loudest on health exploration rather than quieter, or at least you would hope that it should be accentuated because of that. It may be associated with signs of LV failure or heart failure. So looking for race, juggerabinus pressure, bibaseal cappetations or peripheral or sacral edema. And if you're feeling the pulse, always check for a slow rising pulse that's weak and late relative to its expected characteristics. So once you get to the end of the examination, you'll be expected to present the patient back to the examiner with your findings followed by some questioning. Myself and Steve are going to take a very quick break, but don't go anywhere because when we're back we'll be covering the common sorts of questions which you may be asked by the examiner's and hopefully give you the correct answers to those questions. We'll be back in just a couple of moments. Welcome back to the Pre Paces Podcast where we are joined by Dr. Steve Dorman, a consultant interventional cardiologist who subspecialises in the tabby service at the Bristol Heart Institute. So we've spoken a bit already about the examination aspect of a patient with aeltics stenosis. And now we're moving on to the four minutes after the examination where you'll face questions from the examiner. And at least what I've been taught from my seniors, which you may agree with Steve, I don't know, you're often encouraged to spontaneously present the patient, present the pertinent findings and then almost in continuation of your presentation discuss the differential diagnoses, the investigations and the management. So why don't we cover each of those in turn? What would you want a candidate to cover in the differential diagnoses of a patient with aeltics stenosis? So essentially you want to come away from this examination and hopefully you'll you'll be picked up. a systolic murmur. You may or may not be confident that it's AS or it could be something else. So the first question I would ask as an examiner or in your presentation is, I want you to know what's the differential diagnosis of a systolic murmur. Now, you may be good enough to know it's an injection systolic versus a pan systolic and you may have picked up all those subtle clinical signs that lead you to it. But I don't think the examiner cares as long as your consistent. So consistency is the most important thing. So if your confidence is an injection systolic murmur, I would lead off with there is an injection systolic murmur consistent with aortic stenosis. However, I would like to see an ECG to confirm this evidence of left ventricular hypertrophy and evidence of an echocardiogram to confirm the gradients. If you're not so confident, you could say, there's clearly a systolic murmur. My principal differential diagnosis here would be with a mitral regurgisant murmur. The patient's age suggests it's unlikely to be a hypertrophic cardiomyopathy murmur. And the other murmurs, pulmonary stenosis, vanishing you rare, VSD tends to be in a post-infoxinary, you're going to be at least 50 or 60 and your mortality post-VSD is very unless it's a congenital VSD, of course, in which case they'll be very young. But if they're a post-infoxin VSD, it's unlikely. So the ages are really good discriminator here before you lead off. Yeah, absolutely. So although obviously we said at the head of the podcast that we wouldn't be covering the congenital aspects in detail, they are important to know as they are potential differential diagnoses for a patient with a systolic murmur. And I guess one other thing just to mention and highlight is that aortic sclerosis will cause often a softer systolic murmur. There are a number of differentiating factors between aortic stenosis and sclerosis. So do you know what they are? Clinically, no. I know what your discovery is. I'm very good at looking at the echo these days. I don't think you can tell it, I mean I would say you can tell an aortic sclerotic murmur because it's just much shorter in nature. So listening to an AS murmur that's easier. It's a whew. Whereas it will be a whew whew whew. So it's the best effort I've been doing. As a great impression there of both murmurs. Yeah. So I would agree that it's often at least in my experience, it's a lot softer and a lot shorter and often a lot less harsh sounding than aortic stenosis. And I believe also it doesn't tend to radiate to the corrected as much. And so leading on from there, so you've led out with your differential diagnoses. And then I guess the investigations of which Steve you mentioned a couple already. So an ECG looking for left ventricular hypertrophy and the critical investigation is going to be a necarchal diagram which will come on to. I know we talked about differential diagnoses but often as well they will ask about the etiology of the underlying cause of the aortic stenosis. And in my experience this is often quite age-dependent as to you and you sort of have to make a judgement as to the patient in front of you as to what it could be. And without a history you're very sort of limited in that. But the majority of patients you'll see will be generally elderly but it could be important to mention all the common causes of aortic stenosis. So Steve what are the most common causes that we see as causes of aortic stenosis? So probably 80% of aortic stenosis in the UK populations degenerative calcific. So as soon as your patients between the ages of 70 and 85 that's going to be your most likely gambit. Now true by Cuspid starts presenting from mid-forties up to 60. So by Cuspid, congenital by Cuspid, you do see it that sort of age group. And then there's a grey zone of depending on how you choose to classify your by Cuspid valves. You will see by Cuspids in the elderly population but more often they're not their sort of fused physiological ones rather than true congenital by Cuspids. Romantic fever, I can't say I've seen one in the last couple of years from an aortic valve perspective so we don't really see that. So etiology you know we increasingly think he is rather similar to atherosclerotic disease. It's an inflammatory process associated with some of the typical symptoms. As soon as you've got somebody in their 70s to their mid 80s it's degenerative calcific. That's going to cover up 80% of cases. And by Cuspids probably 5, 10%. The thing you can be certain of is if they're in their 40s or their 50s this is not a tri-cuspid. This is not a tri-leaflet valve. This is almost certainly a by Cuspid valve. There's no certainties but I'll give you 95% chance. Yeah. So I guess the less than air is just obviously the most common cause is degenerative calcification but at least to cover your backs if unsure you can mention it could also be a by Cuspid valve or in extremely rare cases it could be rheumatic fever. Okay so then we can get on to do other questions that the examiner may ask particularly regarding severity of aortic stenosis. And they may mention this with regard to clinical or echocardiographic signs. So Steve what are they? What are the signs that you would rely on to diagnose or ascertain that someone has severe aortic stenosis either clinically or on echocardi? So I think severity is good as good evidence that the nature of the murmur actually predicts severity so cardiologists can independently say this is more severe. So the murmurs the first thing having a slow rising pulse and having evidence of cardiac decomposition. So those three things clinically would immediately make you suspicious. I'm not sure what allowed history here are we. History is not in the examination station. You might get a lead in you might so get a single sentence saying this patient has presented with breathless or chest pain or blackouts. So then we get on to the echo. Basically the echo is the seminal investigation. Most people with proper AS will have LVH on ECG. So if you're given a 12 lead ECG look for left ventricle hybridria is very common. They may have left bundle branch block. And the reason we're interested in the ECG is that 10% of patients who have a tavvy go on to have a pacemaker afterwards. So we are very interested to know if they have pre-existing conduction disease. So I'm always interested to see the ECG, to see if there's LVH and to see if they've got to rate what their chances of needing a pacemaker after the tavvy are. That nevertheless doesn't diagnose the severe AS and what diagnose it is the echo. So you're looking for a peak gradient across the aortic valve of over 64 or a mean gradient of over 40. And those are the standard criteria. Now you can index to body surface area. And a lot of people in the echo community will say that the best measure is in fact the ratio of the velocity across the aortic valve to the velocity in the LVOT. It's called the dimensionless index. And it takes a counter the fact that there's an inherent error when you measure the aortic valve area. So the aortic valve area is in the criteria, but it can be fairly significantly underestimated or over estimated just by where you place your calipers. So we don't really like aortic valve area. We like the dimensionless index which is just a measure of the LVOT velocity ratio relative to the aortic valve. But to keep it simple, sorry to summarize because I'm probably confused you completely buy that. You looking for a peak gradient of over 64 or a mean of over 40. So stick to the gradients. Yeah. Consultant cardiologist don't like the valve area. They like the dimensionless index. Excellent. And then we actually get into your realms, Steve, which is determining whether or not someone would be suitable for a tavi versus a surgical aortic valve replacement. So when you have your tavi MDT, what are the sort of things you consider when considering a patient for an aortic valve replacement or a tavi? So I think to keep it simple, the rule of thumb I would use is if the patient is 75 or over, their default their default strategy should be tavi unless they're not technically favorable. If they're 75 and under, their default strategy should be surgical aortic valve replacement unless the surgeons don't think they're favorable. So that's your starting point. Now the reason behind that is that we only have seven, eight years worth of follow up on tavi valves. And so there are still issues about longevity of tavi valves. As soon as you start putting it in younger people, you're putting it in bicuspid valves. That's an off label indication. There's a higher pacemaker rate with tavi over surgery. And therefore it's a bigger deal in younger person. So anyone under the age of 75 should be referred, I would say, to the heart team, but is likely to get a surgical operation unless there's a good reason not to. By contrast, over 75, all the evidence shows you'll make a much quicker recovery. You'll have higher effective orifice areas. You'll have less atrial fibrillation, less chronic kidney disease, and you'll be bouncing around within sort of 48, 72 hours if you have a tavi. Now the features that make you unsuitable for a tavi or less appealing for a tavi are if you've got bad peripheral vascular disease, if you've got malignant features of the anulus where the valve's going in, so it won't sit correctly. And if you've got a lot of coronary artery disease that's going to be relatively complicated to treat with stents, so those would be the main things that would make me think, okay, this patient isn't looking so straightforward. From a surgical perspective, the surgeons have a number of things they don't like, they don't like porcelain a-autos. If you've had radiotherapy to the chest, they don't like that. If you've had a previous stenotomy, they don't like reopening things understandably. If you've got a patent lemagraph to the LED, they won't be liking that. If you've got chronic liver disease, they won't like that. If you've got pulmonary hypertension, they won't like that. And if you've got a bad left ventricle, they won't like that either. So those will all be reasons why people under the age of 75 might be asked to be considered for a taboo. So the rule of thumb over 75, they need a tabby CT to check their suitability. Under 75, you're probably thinking about a surgical option in the first instance. And what a wonderful segue that takes us onto, which is what is the usual workup for a surgery or a tabby? So as the previous just mentioned there, a tabby gated CT, which will give you a lot of that information regarding the porcelain, or the measurements of their valvular, annulus, etc. So that's a critical part of the workup. But obviously we go back and start with the very basics, routine blood tests as a matter of routine. I always liked to justify by saying we're going to, it may affect any drugs that we choose to start after any procedure. Often if they are a smoker or they have been in the past, the surgeons or indeed your self-steve will want to get some lung function tests to see how well they're doing from that perspective. And as you mentioned, patent lemagraphs or any other reason that they might have coronary artery disease or another reason to perform a bypass operation would be indicated prior to being considered for surgery or a tabby. One thing which I found doing my research for this Steve was the use of carotid Doppler. Do we tend to do those routinely anymore? I certainly don't. I mean if the surgeons want it, they can usually think like carotid Doppler, they're a donor for surgeon, doesn't want to do an operation in the nicest possible way. So they're used, and so increasingly I would say the gatekeeper examination is a tabby, is an ECG-gated CT. You probably need an angiogram if the CT hasn't shown the coronary artery is well enough. And then everything else is pretty much up for discussion, lung function, carotid Doppler's. And it's not mandatory. And certainly we wouldn't be doing them unless we were being led by something. And the advantage of the tabby CT is you get a free look at the lungs with the on the lung windows. So you get a bit of a look there and you might have an indication to be thinking about lung function tests afterwards. Routine Buds, we certainly do have to do. Carotid Doppler's, you'd have to ask a surgeon, I suspect, when you think about the context of A or TXNOS' operations and why you might be doing, making it more complicated and doing, cross-dendar, direct me, I think most of the time you'll find you either just get on and do the valve replacement or you'll further them for a tabby. Excellent. So as we come towards the end, when you come towards the end of the station, you get asked more and more in-depth questions. And some of those might be with untreated A or TXNOS' what are the potential complications of that? And then I guess as you may mention your management with regard to something like a tabby, as it's likely to be an elderly patient, you'll see what are the complications of a tabby. So we've already mentioned a few of these as we've gone through regarding the complications of A or TXNOS' so obviously heart failure as a result, those are the signs we mentioned earlier you'd be looking for. Bradding and Tachiaid, Rhythmias, can occur in this population, as Steve mentioned earlier, hemolytic anemia, not so common that we would see and as we mentioned earlier as well, anemia or angiodeisplasia, haids syndrome as a result of A or TXNOS'. Obviously we keep an eye on the patients that you do the tabbies on the Steve and what complications are we observing for when you've done a tabby in the sort of the peri-procedural period? So the big complications of tabby are the commonest one is needing a pacemaker and that's why we look at the ECG beforehand. 10% of people who have a tabby ultimately go on to need a pacemaker. The next thing is we put a great big tube in their groin and so vascular access accounts for 5% of the complications of tabby and they either need a stent or an operation to fix that and then 2% of the time something pretty awful happens like a stroke, a heart attack, we block a coronary, we have anular rupture, we perforate the apex, it's a wide variety of things that can happen and when I consent a patient for a tabby they always look a little worried at this point and then I have to remind them that actually their prognosis untreated is around 50% one year mortality. So the prognosis of untreated aortic stenosis is worse than the vast majority of cancers and the mortality is higher on the waiting list for tabby than it is from the procedure within the United Kingdom. So we have to get the right perspective for the patient, this is a serious condition but it's entirely treatable and the most likely thing you're going to get is either needing a pacemaker afterwards or a vascular access complication but 2% of the time something pretty bad can happen. I think that brings us pretty nicely to the end of the station so hopefully there we've managed to give you a rundown of the examination aspects of a patient with aortic stenosis, the signs you would look for and then the consults of questions regarding the different diagnosis, investigations and management of a patient with aortic stenosis. So myself and Steve are going to take another very brief break but after the break we're going to be coming back and Steve is going to be the first kidney pig on quiz the consultant where he'll be answering questions on windsurfing foils. So don't go anywhere we'll be back just after a break. Ab welcome back to the pre-paces podcast. We all know consultants are experts in their fields but what else occupies the brilliant minds of our consultants that isn't to do with medicine. I'm laying down the gauntlet to each consultant who comes on the show to give me a specialist subject of their own choosing with the one caveat being it can't be anything to do with medicine. Whoever comes out on top at the end of the series will bag a coveted pre-paces podcast mug. So Steve what have you chosen as your specialist subjects? I've chosen foils for wind surfers and kindturfers. Excellent so this is the way it's going to work so there are 10 questions in total. You can either try and answer it first time for which you've got two points or you can take multiple choice options and that'll give you one point and as I said you're in with a chance to win a coveted pre-paces podcast mug. So 10 questions coming up on wind surf foils. A foil is an underwater glider that allows you to fly over the water by applying what type of force? That's interesting. It's like the force of a wing so it's a hydrodynamic force? Absolutely correct. The two whole points hydrodynamic force. Question number two according to windfoilzone.com what are the perfect conditions to learn to windfoil? You don't want it too windy basically so I would say fours four to two between yeah fours three to four fours three to four they'll probably want as perfect conditions. Okay it's less it's even less complicated than forces. I'm going to so like wind you said light wind which I'm going to give you two points for it's light wind no chop so that's another two points. Number three in windfoiling what is a catapult? I can tell you because I've experienced it it's very painful. You're attached to a harness and you don't manage the board well and you get slung around the front of the board and depending on what you're wearing it's either painful or not painful. It is indeed it's a type of crash. Question number four again according to windfoilzone.com assuming a basic beginner knowledge of foiling how long does it do they say it should take you to an inverter commas get flying and it's a range it's a time range. I would say an hour if you're a decent windsurfer within an hour if you're converting from being a decent now they're probably going to be a bit more conservative so but I would say realistically within one to four hours if you're a decent windsurfer you could be foiling in low wind conditions. I'm going to give it to you it's two to four hours is what they've said you said one to four I'm giving it to you. I'm looking forward to the mug. So which part of the windfoil will give you the ability to fly? Well it's the it's the main foil that's the foil. What are they going to say? You can take the options. Give me some options. Okay is it A the back wing or aka the stabilizer? Is it B the front wing? Is it C the sail or is it D the fuselage? Yeah it's the sail or the front wing and I'm going to and what's the question which is which past the windfoil will give you the ability to fly? Let's go to sail. So they say the back wing. That's another one from windfoilzone.com. I can't argue with them. Okay so we just said that it was the stabilizer that give you the ability to fly. The question is, does a larger stabiliser give you more or less downforce than a small one? Bigger foils will lift you higher up, so I suppose the downforce is more. Absolutely correct. More, it tilts the nose up. Question 7, when surf foils are usually constructed of two materials, name either one. I was carbon fiber, they're very expensive, cost about £2.00. Question 8, another, according to windfoils.com, you can tell where I got my research from. What is the average windfoil cruising speed? I'll give you five knots either way. So you'll be planning and I would hope you would be doing at least 10-15 knots. I would be disappointed if you were doing any less than that, so you may be 15-20. Let's go with 15-20. It's 20 knots, is the correct answer. Question 9, what is the name of the current windfoil world champion? I absolutely know how to do it. Well you have to fall at one hurdle. It's Tom Goyard or Goyard. Never heard of him, I'm sure he's a very successful young man. I'm sure he is. And what part, this is the last question, what part of the foil connects the front wing to the back wing? A fuselage for employees. Absolutely correct. Leading the charge in quiz the consultant. Dr Steve Dorman, thank you so much for being the first guinea pig. I hope you're on quiz the consultant. It's been a pleasure and good luck to you all doing paces. It does get better after paces. So hopefully listeners that will cover all aspects of aortic stenosis. You might be asked to approach in a cardiology station. We have been delighted to be joined by Dr Steve Dorman, consultant cardiologist in tabby at the Bristol Heart Institute to give us all the information we need to tackle this critically important paces station. As you know, we're always trying to improve here at the Pre Paces podcast and we would love to hear from you. You can get in touch via the usual social media channels on Twitter and Instagram. It's @prepacespodcast and on email it's [email protected]. Thank you so much for listening and we'll see you next time on the pre paces podcast. [Music]