Aortic stenosis physical examination: Difference between revisions

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Revision as of 00:38, 10 April 2012

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: {LG}} Mohammed A. Sbeih, M.D. [2]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [3]

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. Among patients with suspected aortic stenosis, cardinal presentation signs include: peripheral edema, pulsus parvus et tardus (a slow-rising, small volume carotid pulse), lag time between apical and carotid impulses, systolic hypertension, and a distinct ejection systolic murmur.

Physical Examination

Vitals

Pulse

Pulsus parvus et tardus which is a low volume, slow rising and/or sustained upstroke of arterial pulse is present secondary to prolongation of the ejection phase.^[1]

Systolic hypertension, particularly more pronounced in patients with supravalvular aortic stenosis

Skin

Neck

Delayed carotid upstroke (apical-carotid delay): noticeable delay between the first heart sound (heard on auscultation) and the corresponding pulse in the carotid artery is present. 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).

Systolic carotid thrill

Lungs

Pulmonary rales may be present in a patient who subsequently develops congestive heart failure

Heart

An easily heard systolic, crescendo-decrescendo (i.e. 'ejection') murmur is heard loudest at the upper right sternal border, and radiates to the carotid arteries bilaterally. The murmur increases with squatting, decreases with 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, the later the peak occurs in the crescendo-decrescendo of the murmur.

The 2nd heart sound tends to become softer as the aortic stenosis becomes more severe. This is a result of the increasing calcification of the valve preventing it from "snapping" shut and producing a sharp, loud sound. Due to increases in left ventricular pressure from the stenotic aortic valve, over time the ventricle may hypertrophy, resulting in a diastolic dysfunction. As a result, one may hear a 4th heart sound due to the stiff ventricle. With continued increases in ventricular pressure, dilatation of the ventricle will occur, and a 3rd heart sound may manifest.

Finally, aortic stenosis often co-exists with some degree of aortic insufficiency. Hence, the physical exam in aortic stenosis may also reveal signs of the latter, for example an early diastolic decrescendo murmur. Indeed, when both valve abnormalities are present, the expected findings of either may be modified or may not even be present. Rather, new signs emerge which reflect the presence of simultaneous aortic stenosis and insufficiency, e.g. pulsus bisferiens.

Abdomen

Extremeties

Peripheral edema may be present in a patient who subsequently develops congestive heart failure

Supportive trial data

A meta analysis,^[1] demonstrated the presence of anacrotic pulse as the most useful finding to rule out aortic stenosis in the clinical setting. The positive likelihood ratio observed across studies for different signs are listed as follows:

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

Signs of Aortic Stenosis

Aortic stenosis murmer. It is mid-systolic ejection murmur that is low-pitched and rough, it is loudest at the base of the heart and transmitted upward along the carotid arteries. The murmer is at least grade III or IV in most patients with severe obstruction, it may be soft in patients with mild degrees of obstruction or in those with heart failure, in whom stroke volume is reduced.
Systolic thrill in the same location of murmur and also at the base of the heart, in the jugular notch, and along carotid arteries.
Early systolic ejection murmer (the opening snap of the aortic valve).
Paradoxical splitting of S2 from prolongation of LV systole.
S4 may be audible at the apex.
S3 generally occurs due to left ventricular dilatation.
Pulsus parvus et tardus. A slow and/or sustained upstroke of the peripheral pulse, and the pulse may be of low volume.
Sustained, thrusting apex beat.
The LV impulse is usually displaced laterally due to left ventricular hypertrophy.
In the left lateral recumbent position, a double apical impulse may be found.
Rhythm is regular, but late in the course, the left atrium dilates and atrial fibrillation develops.
Systolic pressure may decrease and the pulse pressure may narrow late in the course.
The reduction of cardiac output induced by mitral stenosis may mask clinical findings produced by aortic stenosis when they coexist.

Murmur in Aortic Stenosis

References

↑ ^1.0 ^1.1 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. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)

Template:WH Template:WS

[pmid9032164-1] 1.0 ^1.1 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. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)

[1]

@@ Line 1: / Line 1: @@
 {{Aortic stenosis}}
-{{CMG}}; {{AOEIC}} [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@perfuse.org]; '''Assistant Editor-In-Chief:''' [[Kristin Feeney|Kristin Feeney, B.S.]] [mailto:kfeeney@perfuse.org]
+{{CMG}}; {{AOEIC}} {LG}} [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@perfuse.org]; '''Assistant Editor-In-Chief:''' [[Kristin Feeney|Kristin Feeney, B.S.]] [mailto:kfeeney@perfuse.org]
 ==Overview==
-Patient with suspected aortic stenosis may present with signs such as [[peripheral edema]], [[pulsus parvus et tardus]] ''(a slow-rising, small volume carotid pulse)'', lag time between apical and carotid impulses, [[systolic hypertension]], and a distinct [[ejection systolic murmur]].
+Aortic stenosis is most often diagnosed when it is [[asymptomatic]] and can sometimes be detected during routine examination of the heart and circulatory system. Among patients with suspected aortic stenosis, cardinal presentation signs include: [[peripheral edema]], [[pulsus parvus et tardus]] ''(a slow-rising, small volume carotid pulse)'', lag time between apical and carotid impulses, [[systolic hypertension]], and a distinct [[ejection systolic murmur]].
 ==Physical Examination==
-The critically ill patient may be in extremis. Peripheral edema may be present in the patient with CHF. Pulmonary rales may be present in the patient with CHF.
-Aortic stenosis is most often diagnosed when it is [[asymptomatic]] and can sometimes be detected during routine examination of the heart and circulatory system. Good evidence exists to demonstrate that certain characteristics of the peripheral pulse can rule in the diagnosis <ref>http://jama.ama-assn.org/cgi/content/abstract/277/7/564</ref>. In particular, there may be a slow and/or sustained upstroke of the arterial pulse, and the pulse may be of low volume. This is sometimes referred to as ''[[pulsus tardus et parvus]]''. There may also be a noticeable delay between the [[heart sounds|first heart sound]] (on [[auscultation]]) and the corresponding pulse in the [[carotid]] artery (so-called 'apical-carotid delay'). 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).
+===Vitals===
+=====Pulse=====
+*[[Pulsus parvus et tardus]] which is a low volume, slow rising and/or sustained upstroke of arterial pulse is present secondary to prolongation of the ejection phase.<ref name="pmid9032164">{{cite journal |author=Etchells E, Bell C, Robb K |title=Does this patient have an abnormal systolic murmur? |journal=[[JAMA : the Journal of the American Medical Association]] |volume=277 |issue=7 |pages=564–71 |year=1997 |month=February |pmid=9032164 |doi= |url= |accessdate=2012-04-09}}</ref>
+*[[Systolic hypertension]], particularly more pronounced in patients with supravalvular aortic stenosis
+===Skin===
+===Neck===
+*Delayed carotid upstroke (apical-carotid delay): noticeable delay between the [[heart sounds|first heart sound]] (heard on [[auscultation]]) and the corresponding pulse in the [[carotid]] artery is present. 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).
+*Systolic carotid thrill
+===Lungs===
+*[[Rales|Pulmonary rales]] may be present in a patient who subsequently develops [[congestive heart failure]]
+===Heart===
 An easily heard [[systole|systolic]], crescendo-decrescendo (i.e. 'ejection') [[heart murmur|murmur]] is heard loudest at the upper right sternal border, and radiates to the [[carotid artery|carotid arteries]] bilaterally. The murmur increases with squatting, decreases with 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, the later the peak occurs in the crescendo-decrescendo of the murmur.
@@ Line 16: / Line 31: @@
 Finally, aortic stenosis often co-exists with some degree of [[aortic insufficiency]]. Hence, the physical exam in aortic stenosis may also reveal signs of the latter, for example an early diastolic decrescendo murmur. Indeed, when both valve abnormalities are present, the expected findings of either may be modified or may not even be present. Rather, new signs emerge which reflect the presence of simultaneous aortic stenosis and insufficiency, e.g. [[pulsus bisferiens]].
-According to a [[meta analysis]], the most useful findings for ruling in aortic stenosis in the clinical setting were slow rate of rise of the carotid pulse(positive [[likelihood ratio]] ranged 2.8-130 across studies), mid to late peak intensity of the murmur(positive likelihood ratio, 8.0-101), and decreased intensity of the second heart sound(positive likelihood ratio, 3.1-50) <ref>{{cite journal |author=Etchells E, Bell C, Robb K |title=Does this patient have an abnormal systolic murmur? |journal=JAMA |volume=277 |issue=7 |pages=564-71 |year=1997 |pmid=9032164 |doi=}}</ref>.
+===Abdomen===
+===Extremeties===
+*[[Peripheral edema]] may be present in a patient who subsequently develops [[congestive heart failure]]
+==Supportive trial data==
+A [[meta analysis]],<ref name="pmid9032164">{{cite journal |author=Etchells E, Bell C, Robb K |title=Does this patient have an abnormal systolic murmur? |journal=[[JAMA : the Journal of the American Medical Association]] |volume=277 |issue=7 |pages=564–71 |year=1997 |month=February |pmid=9032164 |doi= |url= |accessdate=2012-04-09}}</ref> demonstrated the presence of [[anacrotic pulse]] as the most useful finding to rule out [[aortic stenosis]] in the clinical setting. The positive [[likelihood ratio]] observed across studies for different signs are listed as follows:
+*[[Pulsus parvus et tardus]]- 2.8 to 130
+*Mid to late peak murmur intensity- 8.0-101
+*Decreased intensity of the second heart sound- 3.1-50
 ==Signs of Aortic Stenosis==
-* A slow-rising, small volume carotid pulse.
 *Aortic stenosis murmer. It is mid-systolic ejection murmur that is low-pitched and rough, it is loudest at the base of the heart and transmitted upward along the carotid arteries. The murmer is at least grade III or IV in most patients with severe obstruction, it may be soft in patients with mild degrees of obstruction or in those with heart failure, in whom [[stroke volume is reduced]].
 *Systolic thrill in the same location of murmur and also at the base of the heart, in the jugular notch, and along carotid arteries.