Aortic stenosis physical examination

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Aortic Stenosis Microchapters

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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.[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 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.
  • 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.
  • 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

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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)


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