Aortic stenosis differential diagnosis

Aortic Stenosis Microchapters
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Mohammed A. Sbeih, M.D. [2]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [3]

Overview

Aortic stenosis must be differentiated from other cardiac or pulmonary causes of dyspnea, weakness, and dizziness. Furthermore, if there is left ventricular outflow tract obstruction, it is critical to identify if the obstruction is subvalvular, valvular or supravalvular or due to Hypertrophic Cardiomyopathy (HOCM).

Differentiating Aortic Stenosis from Pulmonary Causes of Dyspnea

AS can be differentiated from pulmonary causes of dyspnea by a narrow pulse pressure, a harsh late-peaking systolic murmur heard best at the right second intercostal space with radiation to the carotid arteries, and a delayed slow-rising carotid upstroke (pulsus parvus et tardus) and signs of heart failure on examination.

Differentiating Aortic Stenosis from Aortic Sclerosis

While a murmur may be heard in aortic sclerosis, there is no fusion of the commisures and no significant obstruction to forward flow across the aortic valve. As a result, the S2 is normal in aortic sclerosis and the carotid upstroke is normal (i.e. pulsus parvus et tardus) is absent.

Differentiating Aortic Stenosis from Mitral Regurgitation

The murmur of aortic stenosis is harsh and best heard at the right second intercostal space while the murmur of mitral regurgitation is blowing and soft and best heard at the apex.

Differentiating Aortic Stenosis from Hypertrophic Obstructive Cardiomyopathy

In HOCM the murmur is dynamic and varies with maneuvers. In HOCM there is a bifid or spoke and dome pattern to the carotid upstroke.

Differentiating Valvular Aortic Stenosis from Subvalvular Aortic Stenosis

Aortic insuffiency is more often present with subvalvular aortic stenosis (in 50% to 75% of cases). Echocardiography identifies a membrane or fibromuscular obstruction. Symptoms begin earlier in life (in childhood or adolescence) than in valvular aortic stenosis.

Differentiating Valvular Aortic Stenosis from Supravalvular Aortic Stenosis

• Uncommon congenital anomaly produced by narrowing of ascending aorta or by fibrous diaphragm with small opening just above aortic valve.

• Fixed Subvalvular Obstruction.

Symptomology associated with fixed subvalvular obstruction includes:

• Presence of subaortic membrane.
• May be difficult to visualise in 2D echocardiography.
• Presents in early adulthood.
• Valve is not stenotic, but doppler shows increased gradient.
• Can be diagnosed with careful search using pulse wave doppler and colour flow mapping.
• Congenital anomaly produced by a membranous diaphragm or a fibrous ridge just below the aortic valve