Aortic stenosis physical examination: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
No edit summary
No edit summary
Line 1: Line 1:
{{Aortic stenosis}}
{{Aortic stenosis}}
{{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]
{{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==
==Overview==
Line 8: Line 8:


===Vitals===
===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>  
*[[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 pressure may decrease with resultant narrow [[pulse pressure]]


*[[Systolic hypertension]], particularly more pronounced in patients with supravalvular aortic stenosis
*[[Systolic hypertension]], particularly more pronounced in patients with supravalvular aortic stenosis
===Skin===


===Neck===
===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).
*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
*[[thrill|Systolic thrill]] at the murmur area, at the base of the heart, in the jugular notch, and along carotid arteries.


===Lungs===
===Lungs===
Line 25: Line 23:


===Heart===
===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.
*'''Apical impulse:'''
:*Usually displaced laterally due to [[left ventricular hypertrophy]]
:*In left lateral recumbent position, a double apical impulse may be present


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.
*'''Heart Sounds:'''
:*S2 tends to become softer with increasing severity of aortic stenosis, secondary to an increase in valve calcification preventing it from "snapping" shut which produces a sharp, loud sound.  


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]].
:*Due to increases in [[left ventricular pressure]] from the stenotic aortic valve, over time the [[LVH|ventricle may hypertrophy]], resulting in [[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.


===Abdomen===
*'''Murmur:'''
:*Crescendo-decrescendo type of [[ejection systolic murmur]]
:*Best heard at the upper right sternal border
:*Bilateral radiation to the [[carotid artery|carotid arteries]]
:*Murmur increases with squatting
:*Murmur 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.


*[[Aortic stenosis]] often co-exists with some degree of [[aortic insufficiency]]. Therefore, signs specific for [[aortic insufficiency]] such as early diastolic decrescendo murmur may be present. In addition, presence of [[pulsus bisferiens]] may indicate the presence of simultaneous [[aortic stenosis]] and [[aortic insufficiency]].
*[[Mitral stenosis]] induced reduction in [[cardiac output]] may mask clinical findings produced by [[aortic stenosis]] when they coexist.
*Rhythm is regular, but late in the course, the left atrium dilates and [[atrial fibrillation]] develops.


===Extremeties===
===Extremeties===
Line 42: Line 55:
*Mid to late peak murmur intensity- 8.0-101  
*Mid to late peak murmur intensity- 8.0-101  
*Decreased intensity of the second heart sound- 3.1-50  
*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==
==Murmur in Aortic Stenosis==

Revision as of 03:23, 10 April 2012

Aortic Stenosis Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

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

Case Studies

Case #1

Aortic stenosis physical examination On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Aortic stenosis physical examination

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Aortic stenosis physical examination

CDC on Aortic stenosis physical examination

Aortic stenosis physical examination in the news

Blogs on Aortic stenosis physical examination

Directions to Hospitals Treating Aortic stenosis physical examination

Risk calculators and risk factors for Aortic stenosis physical examination

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

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

  • 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]

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 thrill at the murmur area, at the base of the heart, in the jugular notch, and along carotid arteries.

Lungs

Heart

  • Apical impulse:
  • Heart Sounds:
  • S2 tends to become softer with increasing severity of aortic stenosis, secondary to an increase in valve calcification preventing it from "snapping" shut which produces a sharp, loud sound.
  • Murmur:
  • Crescendo-decrescendo type of ejection systolic murmur
  • Best heard at the upper right sternal border
  • Bilateral radiation to the carotid arteries
  • Murmur increases with squatting
  • Murmur 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.
  • Rhythm is regular, but late in the course, the left atrium dilates and atrial fibrillation develops.

Extremeties

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

Murmur in Aortic Stenosis

{{#ev:youtube|O4bFK3CGLh8}}

References

  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)


Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=Aortic_stenosis_physical_examination&oldid=640948"