Aortic stenosis physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Maheep Singh Sangha, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S. [2]; Mohammed A. Sbeih, M.D. [3]; Usama Talib, BSc, MD [4] Assistant Editor-In-Chief: Kristin Feeney, B.S. [5]

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. The major signs include pulsus parvus et tardus (a slow-rising, small volume carotid pulse), a lag time between apical and carotid impulses and a distinct systolic ejection murmur.

Physical Examination

Vitals

• Narrow pulse pressure: The systolic pressure may decrease and narrow pulse pressure may be present.
• The rate and rhythm are usually regular, but late in the course of aortic stenosis, the left atrium dilates and atrial fibrillation may develop.

Neck

• Pulsus parvus et tardus is present in aortic stenosis. It is a low volume slow rising pulse with a gradual upstroke. It may be present secondary to prolongation of the ejection phase.
• Pulsus bisferiens may be present in patients with mixed aortic stenosis and aortic regurgitation.
• Delayed carotid upstroke (apical-carotid delay) is present. It is a noticeable delay between the first heart sound (heard on auscultation) and the corresponding pulse in the carotid artery. 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).
• Pulsus alternans may be present if LV systolic dysfunction exists.
• A systolic ejection murmur of aortic stenosis may be transmitted bilaterally to the carotid arteries.
• Reduced right ventricular compliance as a result of interventricular hypertrophy may lead to prominent "a waves" (Bernheim effect).

Heart

Palpation

• Apical impulse:

• Left ventricular hypertrophy secondary to aortic stenosis can produce a heave or lift (palpable impulse) and a laterally displaced apical impulse.
• The presence of a double apical impulse in the left lateral recumbent position is characteristic of hypertrophic obstructive cardiomyopathy rather than aortic stenosis.

• Systolic thrill may be palpated at the right second intercostal space, at the base of the heart, in the jugular notch and along the carotid arteries.

Auscultation

Heart Sounds

The auscultation of the heart in Aortic Stenosis can have the following findings.

• First heart sound, S1 is normal.
• Second heart sound, S2:

• Early in the disease, S2 is soft and single because of slight delay in closure of aortic valve which then coincides with closure of pulmonic valve.
• As the disease progresses, paradoxical splitting of S2 is present with A2 taking place after P2.
• A2 tends to become quiet or absent with increasing severity of aortic stenosis. The reason for this change is that as the valve calcification increases, it prevents the valve from 'snapping' shut. As a consequence, the valve no longer produces a sharp, crisp, loud closing sound.
• A 'reverse S2 spilt' may be observed with aortic stenosis, wherein the S2 split widens during the expiratory phase.
• P2 is accentuated if pulmonary hypertension is present.

• Third and Fourth heart sound:

• The left ventricle may hypertrophy secondary to the sustained increase in the left ventricular pressure. The resulting diastolic dysfunction will produce a fourth heart sound, S4.
• The persistent increase in the ventricular pressures will cause ventricular dilatation and consequently a third heart sound, S3.

• Ejection click:

• In children and young adults, who present with congenitial aortic stenosis, an ejection click is common.
• It is present after S1, and
• Best heard at the lower left sternal border which often spreads to cardiac apex.
• It may be confused as a split S1.
• In elderly patients, who present with acquired calcific aortic stenosis, ejection clicks may be absent due to the rigid valve cusps (severely calcified and immobile).

Murmur

Aortic Stenosis can present with the following characteristics of the associated murmur.

• Crescendo-decrescendo type of ejection systolic murmur is present.
• It is a rough, low pitched sound.
• Best heard at the upper right sternal border.
• Bilateral radiation to the carotid arteries is present.
• The murmur increases with squatting.
• The murmur decreases with valsalva maneuver, 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 is, the later the peak of the murmur occurs.
• In elderly patients with calcific aortic stenosis, murmur may be best heard at the cardiac apex thus confusing it with mitral regurgitation (Gallavardin phenomenon).
• Murmur may become inaudible if cardiac output decreases as a result of left ventricle failure.
• 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 may reduce the cardiac output and may in turn mask the clinical findings of aortic stenosis when the two valvular diseases coexist.

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Lungs

• In a patient with Aortic Stenosis, Pulmonary rales may be present when congestive heart failure has developed.

Extremeties

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

Relative Value of Various Physical Examination Findngs

A meta analysis demonstrated the presence of pulsus parvus et tardus (anacrotic pulse) as the most useful finding to rule in aortic stenosis in the clinical setting. The positive likelihood ratio of different findings observed across multiple studies were:

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

The most important sign to rule out aortic stenosis was the absence of a murmur radiating to the right carotid artery (negative likelihood ratio, 0.05-0.10).