Aortic stenosis physical examination

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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 with a gradual upstroke pulse may be present secondary to prolongation of the ejection phase.

• Pulsus bisferiens may be present in patients with mixed aortic stenosis and aortic regurgitation

• Systolic pressure may decrease with resultant narrow pulse pressure

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

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

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

Heart

• Apical impulse:

• Characteristic left ventricular hypertrophy secondary to aortic stenosis can produce a heave (palpable impulse) and laterally displaced apex.
• In left lateral recumbent position, a double apical impulse if present is characteristic of hypertrophic obstructive cardiomyopathy

• Heart Sounds:

• S2 tends to become quiet or absent with increasing severity of aortic stenosis, secondary to an increase in valve calcification preventing it from "snapping" shut which produces a sharp, loud sound.
• Additionally, reverse S2 spilt may be observed with aortic stenosis, wherein the S2 split widens in the expiration phase.

• Secondary to the sustained increase in left ventricular pressure, over time the left ventricle may hypertrophy, resulting in diastolic dysfunction and consequent production of an S4 (due to forceful atrial contraction against the stiff ventricle). With continued increase in ventricular pressure, ventricular dilatation ensues, and an S3 may manifest.

• 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.
• Ejection clicks may be absent in severely calcified aortic stenosis due to the rigid valve cusps.

• 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

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

Supportive trial data

A meta analysis, 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

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References

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