Aortic stenosis physical examination

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Overview

Classification

Acquired:
Rheumatic Aortic Stenosis
Congenital:
Bicuspid Aortic Stenosis
Subaortic Stenosis
Subvalvular Aortic Stenosis
Supravalvular Aortic Stenosis
Stages
Low Flow, Low Gradient Aortic Stenosis

Pathophysiology

Causes

Differentiating Aortic Stenosis from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Cardiac Stress Test

Electrocardiogram

Chest X Ray

CT

MRI

Echocardiography

Cardiac Catheterization

Aortic Valve Area

Aortic Valve Area Calculation

Treatment

General Approach

Medical Therapy

Surgery

Percutaneous Aortic Balloon Valvotomy (PABV) or Aortic Valvuloplasty

Transcatheter Aortic Valve Replacement (TAVR)

TAVR vs SAVR
Critical Pathway
Patient Selection
Imaging
Evaluation
Valve Types
TAVR Procedure
Post TAVR management
AHA/ACC Guideline Recommendations

Follow Up

Prevention

Precautions and Prophylaxis

Cost-Effectiveness of Therapy

Future or Investigational Therapies

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Case #1

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Maheep Singh Sangha, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S. [2]; Mohammed A. Sbeih, M.D. [3]; Usama Talib, BSc, MD [4] Assistant Editor-In-Chief: Kristin Feeney, B.S. [5]

Overview

Aortic stenosis is most often diagnosed when it is asymptomatic and can sometimes be detected during routine examination of the heart and circulatory system. The major signs include pulsus parvus et tardus (a slow-rising, small volume carotid pulse), a lag time between apical and carotid impulses and a distinct systolic ejection murmur.[1][2]

Physical Examination

Vitals

Neck

  • Pulsus parvus et tardus is present in aortic stenosis. It is a low volume slow rising pulse with a gradual upstroke. It may be present secondary to prolongation of the ejection phase.[6]
  • Pulsus bisferiens may be present in patients with mixed aortic stenosis and aortic regurgitation.[7]
  • Delayed carotid upstroke (apical-carotid delay) is present. [8] It is a noticeable delay between the first heart sound (heard on auscultation) and the corresponding pulse in the carotid artery. Similarly, there may be a delay between the appearance of each pulse in the brachial artery (in the arm) and the radial artery (in the wrist).
  • Pulsus alternans may be present if LV systolic dysfunction exists.[9]
  • A systolic ejection murmur of aortic stenosis may be transmitted bilaterally to the carotid arteries.
  • Reduced right ventricular compliance as a result of interventricular hypertrophy may lead to prominent "a waves" (Bernheim effect).[10]

Heart

Palpation

Auscultation

Heart Sounds

The auscultation of the heart in Aortic Stenosis can have the following findings.[14][12][15]

  • First heart sound, S1 is normal.
  • Second heart sound, S2:
  • Early in the disease, S2 is soft and single because of slight delay in closure of aortic valve which then coincides with closure of pulmonic valve.
  • As the disease progresses, paradoxical splitting of S2 is present with A2 taking place after P2.
  • A2 tends to become quiet or absent with increasing severity of aortic stenosis. The reason for this change is that as the valve calcification increases, it prevents the valve from 'snapping' shut. As a consequence, the valve no longer produces a sharp, crisp, loud closing sound.
  • A 'reverse S2 spilt' may be observed with aortic stenosis, wherein the S2 split widens during the expiratory phase.
  • P2 is accentuated if pulmonary hypertension is present.
  • Third and Fourth heart sound:
  • Ejection click:
  • In children and young adults, who present with congenitial aortic stenosis, an ejection click is common.
  • It is present after S1, and
  • Best heard at the lower left sternal border which often spreads to cardiac apex.
  • It may be confused as a split S1.
  • In elderly patients, who present with acquired calcific aortic stenosis, ejection clicks may be absent due to the rigid valve cusps (severely calcified and immobile).
Murmur

Aortic Stenosis can present with the following characteristics of the associated murmur.[16][12]

  • Crescendo-decrescendo type of ejection systolic murmur is present.
  • It is a rough, low pitched sound.
  • Best heard at the upper right sternal border.
  • Bilateral radiation to the carotid arteries is present.
  • The murmur increases with squatting.
  • The murmur decreases with valsalva maneuver, standing and isometric muscular contraction, which helps distinguish it from hypertrophic obstructive cardiomyopathy (HOCM).
  • The murmur is louder during expiration, but is also easily heard during inspiration.
  • The more severe the degree of the stenosis is, the later the peak of the murmur occurs.
  • In elderly patients with calcific aortic stenosis, murmur may be best heard at the cardiac apex thus confusing it with mitral regurgitation (Gallavardin phenomenon).
  • Murmur may become inaudible if cardiac output decreases as a result of left ventricle failure.
  • Aortic stenosis often co-exists with some degree of aortic insufficiency:

Lungs

Extremeties

[20][12]

Relative Value of Various Physical Examination Findngs

A meta analysis demonstrated the presence of pulsus parvus et tardus (anacrotic pulse) as the most useful finding to rule in aortic stenosis in the clinical setting. The positive likelihood ratio of different findings observed across multiple studies were:[6][21]

  • Pulsus parvus et tardus: 2.8-130
  • Mid to late peak murmur intensity: 8.0-101
  • Decreased intensity of the second heart sound: 3.1-50

The most important sign to rule out aortic stenosis was the absence of a murmur radiating to the right carotid artery (negative likelihood ratio, 0.05-0.10).

References

  1. Mody MR, Nadas AS, Bernhard WF (1967). "Aortic stenosis in infants.". N Engl J Med. 276 (15): 832–8. PMID 6020739. doi:10.1056/NEJM196704132761503. 
  2. Christophe Tribouilloy, Yohann Bohbot, Sylvestre Marechaux, Nicolas Debry, Quentin Delpierre, Marcel Peltier, Momar Diouf, Michel Slama, David Messika-Zeitoun & Dan Rusinaru (2016). "Outcome Implication of Aortic Valve Area Normalized to Body Size in Asymptomatic Aortic Stenosis". Circulation. Cardiovascular imaging. 9 (11). PMID 27903539. doi:10.1161/CIRCIMAGING.116.005121. 
  3. Bermejo J (2005). "The effects of hypertension on aortic valve stenosis.". Heart. 91 (3): 280–2. PMC 1768786Freely accessible. PMID 15710699. doi:10.1136/hrt.2004.041749. 
  4. J. BERGERON, W. H. ABELMANN, H. VAZQUEZ-MILAN & L. B. ELLIS (1954). "Aortic stenosis; clinical manifestations and course of the disease; review of one hundred proved cases". A.M.A. archives of internal medicine. 94 (6): 911–924. PMID 13217489. 
  5. Y. J. Won, B. G. Lim, D. Chung, E. Park, H. Kim, I. O. Lee & M. H. Kong (2016). "Use of Terlipressin in an Elderly Patient With Moderate Aortic Valve Stenosis Accompanied by Episodic Atrial Fibrillation During Liver Transplantation: A Case Report". Transplantation proceedings. 48 (9): 3203–3206. PMID 27932181. doi:10.1016/j.transproceed.2016.02.082. 
  6. 6.0 6.1 Etchells E, Bell C, Robb K (1997). "Does this patient have an abnormal systolic murmur?". JAMA : the Journal of the American Medical Association. 277 (7): 564–71. PMID 9032164. 
  7. FLEMING PR (1957). "The mechanism of the pulsus bisferiens.". Br Heart J. 19 (4): 519–24. PMC 503962Freely accessible. PMID 13471818. 
  8. Blase A. Carabello & Walter J. Paulus (2009). "Aortic stenosis". Lancet (London, England). 373 (9667): 956–966. PMID 19232707. doi:10.1016/S0140-6736(09)60211-7. 
  9. R. H. Swanton, B. S. Jenkins, I. A. Brooksby & M. M. Webb-Peploe (1976). "An analysis of pulsus alternans in aortic stenosis". European journal of cardiology. 4 (1): 39–47. PMID 1261578. 
  10. L. Resnekov (1993). "Aortic valve stenosis. Management in children and adults". Postgraduate medicine. 93 (6): 107–110. PMID 8483818. 
  11. S. J. Galloway, W. J. Casarella & P. M. Shimkin (1974). "Vascular malformations of the right colon as a cause of bleeding in patients with aortic stenosis". Radiology. 113 (1): 11–15. PMID 4547644. doi:10.1148/113.1.11. 
  12. 12.0 12.1 12.2 12.3 12.4 Maganti K, Rigolin VH, Sarano ME, Bonow RO (2010). "Valvular heart disease: diagnosis and management.". Mayo Clin Proc. 85 (5): 483–500. PMC 2861980Freely accessible. PMID 20435842. doi:10.4065/mcp.2009.0706. 
  13. S. J. Galloway, W. J. Casarella & P. M. Shimkin (1974). "Vascular malformations of the right colon as a cause of bleeding in patients with aortic stenosis". Radiology. 113 (1): 11–15. PMID 4547644. doi:10.1148/113.1.11. 
  14. Ilias Maglogiannis, Euripidis Loukis, Elias Zafiropoulos & Antonis Stasis (2009). "Support Vectors Machine-based identification of heart valve diseases using heart sounds". Computer methods and programs in biomedicine. 95 (1): 47–61. PMID 19269056. doi:10.1016/j.cmpb.2009.01.003. 
  15. Chance M. Witt, William R. Miranda & Darrell B. Newman (2016). "The maverick heart sound". Heart (British Cardiac Society). 102 (13): 1008. PMID 26919867. doi:10.1136/heartjnl-2015-309131. 
  16. Atsuko Furukawa, Yukio Abe, Makoto Ito, Chiharu Tanaka, Kazato Ito, Ryushi Komatsu, Kazuo Haze, Takahiko Naruko, Minoru Yoshiyama & Junichi Yoshikawa (2017). "Prediction of aortic stenosis-related events in patients with systolic ejection murmur using pocket-sized echocardiography". Journal of cardiology. 69 (1): 189–194. PMID 27012751. doi:10.1016/j.jjcc.2016.02.021. 
  17. Jason M. Tarkin, James H. F. Rudd, David R. Jayne, Rosemary A. Rusk & Deepa Gopalan (2016). "An unusual finding in a 57-year-old woman with new onset hypertension and a diastolic murmur". Heart (British Cardiac Society). 102 (21): 1762. PMID 27411841. doi:10.1136/heartjnl-2016-309661. 
  18. Lennart van Gils, Marie-Annick Clavel, Mara Vollema, Victoria Delgado, Tamim Nazif, Ernest Spitzer, Rebecca Hahn, Jeroen Bax, Martin Leon, Philippe Pibarot & Nicolas Van Mieghem (2016). "TCT-819 Clinical Outcome in Patients with Heart Failure and Moderate Aortic Stenosis". Journal of the American College of Cardiology. 68 (18S): B331–B332. PMID 27970209. doi:10.1016/j.jacc.2016.09.910. 
  19. Ross J, Braunwald E (1968). "Aortic stenosis.". Circulation. 38 (1 Suppl): 61–7. PMID 4894151. 
  20. Michael Behnes, Siegfried Lang, Ole-A. Breithardt, Jens J. Kaden, Dariusch Haghi, Parviz Ahmad-Nejad, Elif Elmas, Christian Wolpert, Martin Borggrefe, Michael Neumaier & Martina Brueckmann (2008). "Association of NT-proBNP with severity of heart valve disease in a medical patient population presenting with acute dyspnea or peripheral edema". The Journal of heart valve disease. 17 (5): 557–565. PMID 18980090. 
  21. Loay S. Kabbani, Semeret Munie, Judith Lin, Mauricio Velez, Iyad Isseh, Sara Brooks, Stephanie Leix & Alexander D. Shepard (2016). "Flow Patterns in the Carotid Arteries of Patients with Left Ventricular Assist Devices". Annals of vascular surgery. PMID 27531092. doi:10.1016/j.avsg.2016.05.119. 


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