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| [[File:Siren.gif|30px|link=Aortic stenosis resident survival guide]]|| <br> || <br>
| [[Aortic stenosis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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{{Aortic stenosis}}
{{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}} [[User:Maheep Sangha|Maheep Singh Sangha, M.B.B.S.]]; {{LG}}; [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@wikidoc.org]; {{USAMA}} '''Assistant Editor-In-Chief:''' [[Kristin Feeney|Kristin Feeney, B.S.]] [mailto:kfeeney@elon.edu]


==Overview==
==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. 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]].<ref name="pmid6020739">{{cite journal| author=Mody MR, Nadas AS, Bernhard WF| title=Aortic stenosis in infants. | journal=N Engl J Med | year= 1967 | volume= 276 | issue= 15 | pages= 832-8 | pmid=6020739 | doi=10.1056/NEJM196704132761503 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6020739  }} </ref><ref>{{Cite journal
| author = [[Christophe Tribouilloy]], [[Yohann Bohbot]], [[Sylvestre Marechaux]], [[Nicolas Debry]], [[Quentin Delpierre]], [[Marcel Peltier]], [[Momar Diouf]], [[Michel Slama]], [[David Messika-Zeitoun]] & [[Dan Rusinaru]]
| title = Outcome Implication of Aortic Valve Area Normalized to Body Size in Asymptomatic Aortic Stenosis
| journal = [[Circulation. Cardiovascular imaging]]
| volume = 9
| issue = 11
| year = 2016
| month = November
| doi = 10.1161/CIRCIMAGING.116.005121
| pmid = 27903539
}}</ref>


==Physical Examination==
==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===
*[[Narrow pulse pressure]]: The systolic pressure may decrease and narrow [[pulse pressure]] may be present.<ref name="pmid15710699">{{cite journal| author=Bermejo J| title=The effects of hypertension on aortic valve stenosis. | journal=Heart | year= 2005 | volume= 91 | issue= 3 | pages= 280-2 | pmid=15710699 | doi=10.1136/hrt.2004.041749 | pmc=1768786 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15710699  }} </ref><ref>{{Cite journal
| author = [[J. BERGERON]], [[W. H. ABELMANN]], [[H. VAZQUEZ-MILAN]] & [[L. B. ELLIS]]
| title = Aortic stenosis; clinical manifestations and course of the disease; review of one hundred proved cases
| journal = [[A.M.A. archives of internal medicine]]
| volume = 94
| issue = 6
| pages = 911–924
| year = 1954
| month = December
| pmid = 13217489
}}</ref>
*The rate and rhythm are usually regular, but late in the course of aortic stenosis, the [[left atrium]] dilates and [[atrial fibrillation]] may develop.<ref>{{Cite journal
| author = [[Y. J. Won]], [[B. G. Lim]], [[D. Chung]], [[E. Park]], [[H. Kim]], [[I. O. Lee]] & [[M. H. Kong]]
| title = Use of Terlipressin in an Elderly Patient With Moderate Aortic Valve Stenosis Accompanied by Episodic Atrial Fibrillation During Liver Transplantation: A Case Report
| journal = [[Transplantation proceedings]]
| volume = 48
| issue = 9
| pages = 3203–3206
| year = 2016
| month = November
| doi = 10.1016/j.transproceed.2016.02.082
| pmid = 27932181
}}</ref>


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.
===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.<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 bisferiens]] may be present in patients with mixed [[aortic stenosis]] and [[aortic regurgitation]].<ref name="pmid13471818">{{cite journal| author=FLEMING PR| title=The mechanism of the pulsus bisferiens. | journal=Br Heart J | year= 1957 | volume= 19 | issue= 4 | pages= 519-24 | pmid=13471818 | doi= | pmc=503962 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13471818  }} </ref>
* Delayed carotid upstroke (apical-carotid delay) is present. <ref>{{Cite journal
| author = [[Blase A. Carabello]] & [[Walter J. Paulus]]
| title = Aortic stenosis
| journal = [[Lancet (London, England)]]
| volume = 373
| issue = 9667
| pages = 956–966
| year = 2009
| month = March
| doi = 10.1016/S0140-6736(09)60211-7
| pmid = 19232707
}}</ref> It is a noticeable delay between the [[heart sounds|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.<ref>{{Cite journal
| author = [[R. H. Swanton]], [[B. S. Jenkins]], [[I. A. Brooksby]] & [[M. M. Webb-Peploe]]
| title = An analysis of pulsus alternans in aortic stenosis
| journal = [[European journal of cardiology]]
| volume = 4
| issue = 1
| pages = 39–47
| year = 1976
| month = March
| pmid = 1261578
}}</ref> 
* 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 wave]]s" (Bernheim effect).<ref>{{Cite journal
| author = [[L. Resnekov]]
| title = Aortic valve stenosis. Management in children and adults
| journal = [[Postgraduate medicine]]
| volume = 93
| issue = 6
| pages = 107–110
| year = 1993
| month = May
| pmid = 8483818
}}</ref>


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===
====Palpation====
* Apical impulse:<ref>{{Cite journal
| author = [[S. J. Galloway]], [[W. J. Casarella]] & [[P. M. Shimkin]]
| title = Vascular malformations of the right colon as a cause of bleeding in patients with aortic stenosis
| journal = [[Radiology]]
| volume = 113
| issue = 1
| pages = 11–15
| year = 1974
| month = October
| doi = 10.1148/113.1.11
| pmid = 4547644
}}</ref><ref name="pmid20435842">{{cite journal| author=Maganti K, Rigolin VH, Sarano ME, Bonow RO| title=Valvular heart disease: diagnosis and management. | journal=Mayo Clin Proc | year= 2010 | volume= 85 | issue= 5 | pages= 483-500 | pmid=20435842 | doi=10.4065/mcp.2009.0706 | pmc=2861980 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20435842  }} </ref>
:* [[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]].
* [[thrill|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]].<ref>{{Cite journal
| author = [[S. J. Galloway]], [[W. J. Casarella]] & [[P. M. Shimkin]]
| title = Vascular malformations of the right colon as a cause of bleeding in patients with aortic stenosis
| journal = [[Radiology]]
| volume = 113
| issue = 1
| pages = 11–15
| year = 1974
| month = October
| doi = 10.1148/113.1.11
| pmid = 4547644
}}</ref>


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]].
====Auscultation====
=====Heart Sounds=====
The auscultation of the heart in [[Aortic Stenosis]] can have the following findings.<ref>{{Cite journal
| author = [[Ilias Maglogiannis]], [[Euripidis Loukis]], [[Elias Zafiropoulos]] & [[Antonis Stasis]]
| title = Support Vectors Machine-based identification of heart valve diseases using heart sounds
| journal = [[Computer methods and programs in biomedicine]]
| volume = 95
| issue = 1
| pages = 47–61
| year = 2009
| month = July
| doi = 10.1016/j.cmpb.2009.01.003
| pmid = 19269056
}}</ref><ref name="pmid20435842">{{cite journal| author=Maganti K, Rigolin VH, Sarano ME, Bonow RO| title=Valvular heart disease: diagnosis and management. | journal=Mayo Clin Proc | year= 2010 | volume= 85 | issue= 5 | pages= 483-500 | pmid=20435842 | doi=10.4065/mcp.2009.0706 | pmc=2861980 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20435842  }} </ref><ref>{{Cite journal
| author = [[Chance M. Witt]], [[William R. Miranda]] & [[Darrell B. Newman]]
| title = The maverick heart sound
| journal = [[Heart (British Cardiac Society)]]
| volume = 102
| issue = 13
| pages = 1008
| year = 2016
| month = July
| doi = 10.1136/heartjnl-2015-309131
| pmid = 26919867
}}</ref>


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>.
* 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.


==Signs of Aortic Stenosis==
* Third and Fourth heart sound:
* A slow-rising, small volume carotid pulse.
:* The [[LVH|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]].
*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]].
:* The persistent increase in the ventricular pressures will cause ventricular dilatation and consequently a third heart sound, [[S3]].
*Systolic thrill in the same location of murmur and also at the base of the heart, in the jugular notch, and along carotid arteries.
*Ejection click:
*Early systolic ejection murmer (the opening snap of the aortic valve).
:* In children and young adults, who present with congenitial aortic stenosis, an ejection click is common.
*Paradoxical splitting of S2 from prolongation of LV systole.
:* It is present after S1, and
*S4 may be audible at the apex.
:* Best heard at the lower left sternal border which often spreads to cardiac apex.
*S3 generally occurs due to left ventricular dilatation.
:* It may be confused as a split S1.
*Pulsus parvus et tardus. A slow and/or sustained upstroke of the peripheral pulse, and the pulse may be of low volume.
:* In elderly patients, who present with acquired calcific aortic stenosis, [[ejection systolic murmur|ejection clicks]] may be absent due to the rigid valve cusps (severely calcified and immobile).
* Sustained, thrusting apex beat.
 
*The LV impulse is usually displaced laterally due to left ventricular hypertrophy.
=====Murmur=====
*In the left lateral recumbent position, a double apical impulse may be found.
Aortic Stenosis can present with the following characteristics of the associated murmur.<ref>{{Cite journal
*Rhythm is regular, but late in the course, the left atrium dilates and [[atrial fibrillation]] develops.
| author = [[Atsuko Furukawa]], [[Yukio Abe]], [[Makoto Ito]], [[Chiharu Tanaka]], [[Kazato Ito]], [[Ryushi Komatsu]], [[Kazuo Haze]], [[Takahiko Naruko]], [[Minoru Yoshiyama]] & [[Junichi Yoshikawa]]
*Systolic pressure may decrease and the [[pulse pressure]] may narrow late in the course.
| title = Prediction of aortic stenosis-related events in patients with systolic ejection murmur using pocket-sized echocardiography
*The reduction of cardiac output induced by mitral stenosis may mask clinical findings produced by aortic stenosis when they coexist.
| journal = [[Journal of cardiology]]
| volume = 69
| issue = 1
| pages = 189–194
| year = 2017
| month = January
| doi = 10.1016/j.jjcc.2016.02.021
| pmid = 27012751
}}</ref><ref name="pmid20435842">{{cite journal| author=Maganti K, Rigolin VH, Sarano ME, Bonow RO| title=Valvular heart disease: diagnosis and management. | journal=Mayo Clin Proc | year= 2010 | volume= 85 | issue= 5 | pages= 483-500 | pmid=20435842 | doi=10.4065/mcp.2009.0706 | pmc=2861980 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20435842  }} </ref>
* 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 artery|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.<ref>{{Cite journal
| author = [[Jason M. Tarkin]], [[James H. F. Rudd]], [[David R. Jayne]], [[Rosemary A. Rusk]] & [[Deepa Gopalan]]
| title = An unusual finding in a 57-year-old woman with new onset hypertension and a diastolic murmur
| journal = [[Heart (British Cardiac Society)]]
| volume = 102
| issue = 21
| pages = 1762
| year = 2016
| month = November
| doi = 10.1136/heartjnl-2016-309661
| pmid = 27411841
}}</ref>
:* 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.
 
{{#ev:youtube|MJg257pyt4I}}


==Murmur in Aortic Stenosis==
{{#ev:youtube|O4bFK3CGLh8}}
{{#ev:youtube|O4bFK3CGLh8}}
===Lungs===
*In a patient with [[Aortic Stenosis]], [[Rales|Pulmonary rales]] may be present when [[congestive heart failure]] has developed.<ref>{{Cite journal
| author = [[Lennart van Gils]], [[Marie-Annick Clavel]], [[Mara Vollema]], [[Victoria Delgado]], [[Tamim Nazif]], [[Ernest Spitzer]], [[Rebecca Hahn]], [[Jeroen Bax]], [[Martin Leon]], [[Philippe Pibarot]] & [[Nicolas Van Mieghem]]
| title = TCT-819 Clinical Outcome in Patients with Heart Failure and Moderate Aortic Stenosis
| journal = [[Journal of the American College of Cardiology]]
| volume = 68
| issue = 18S
| pages = B331–B332
| year = 2016
| month = November
| doi = 10.1016/j.jacc.2016.09.910
| pmid = 27970209
}}</ref><ref name="pmid4894151">{{cite journal| author=Ross J, Braunwald E| title=Aortic stenosis. | journal=Circulation | year= 1968 | volume= 38 | issue= 1 Suppl | pages= 61-7 | pmid=4894151 | doi= | pmc= | url= }} </ref><ref name="pmid20435842">{{cite journal| author=Maganti K, Rigolin VH, Sarano ME, Bonow RO| title=Valvular heart disease: diagnosis and management. | journal=Mayo Clin Proc | year= 2010 | volume= 85 | issue= 5 | pages= 483-500 | pmid=20435842 | doi=10.4065/mcp.2009.0706 | pmc=2861980 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20435842  }} </ref>
===Extremeties===
* [[Peripheral edema]] may be present in a patient who subsequently develops [[congestive heart failure]].
<ref>{{Cite journal
| author = [[Michael Behnes]], [[Siegfried Lang]], [[Ole-A. Breithardt]], [[Jens J. Kaden]], [[Dariusch Haghi]], [[Parviz Ahmad-Nejad]], [[Elif Elmas]], [[Christian Wolpert]], [[Martin Borggrefe]], [[Michael Neumaier]] & [[Martina Brueckmann]]
| title = Association of NT-proBNP with severity of heart valve disease in a medical patient population presenting with acute dyspnea or peripheral edema
| journal = [[The Journal of heart valve disease]]
| volume = 17
| issue = 5
| pages = 557–565
| year = 2008
| month = September
| pmid = 18980090
}}</ref><ref name="pmid20435842">{{cite journal| author=Maganti K, Rigolin VH, Sarano ME, Bonow RO| title=Valvular heart disease: diagnosis and management. | journal=Mayo Clin Proc | year= 2010 | volume= 85 | issue= 5 | pages= 483-500 | pmid=20435842 | doi=10.4065/mcp.2009.0706 | pmc=2861980 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20435842  }} </ref>
==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:<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><ref>{{Cite journal
| author = [[Loay S. Kabbani]], [[Semeret Munie]], [[Judith Lin]], [[Mauricio Velez]], [[Iyad Isseh]], [[Sara Brooks]], [[Stephanie Leix]] & [[Alexander D. Shepard]]
| title = Flow Patterns in the Carotid Arteries of Patients with Left Ventricular Assist Devices
| journal = [[Annals of vascular surgery]]
| year = 2016
| month = August
| doi = 10.1016/j.avsg.2016.05.119
| pmid = 27531092
}}</ref>
*[[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).


==References==
==References==
{{reflist|2}}
{{reflist|2}}
[[es:Estenosis aórtica]]
[[fr:Rétrécissement aortique]]
[[pl:Stenoza Aortalnej]]
[[pt:Estenose aórtica]]
[[ro:Stenoza Aortic?]]
[[tr:Aort darl???]]
{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[CME Category::Cardiology]]


[[Category:Signs and symptoms]]
[[Category:Physical Examination]]
[[Category:Disease]]
[[Category:Disease]]
[[Category:Valvular heart disease]]
[[Category:Valvular heart disease]]
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Congenital heart disease]]
[[Category:Congenital heart disease]]
[[Category:Mature chapter]]
[[Category:Cardiac surgery]]
[[Category:Cardiac surgery]]
[[Category:Surgery]]
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Latest revision as of 16:05, 5 January 2017
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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.[1][2]

Physical Examination

Vitals

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.[6]
  • Pulsus bisferiens may be present in patients with mixed aortic stenosis and aortic regurgitation.[7]
  • Delayed carotid upstroke (apical-carotid delay) is present. [8] 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.[9]
  • 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).[10]

Heart

Palpation

Auscultation

Heart Sounds

The auscultation of the heart in Aortic Stenosis can have the following findings.[14][12][15]

  • 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:
  • 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.[16][12]

  • 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:

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Lungs

Extremeties

[20][12]

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:[6][21]

  • 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).

References

  1. ↑ Mody MR, Nadas AS, Bernhard WF (1967). "Aortic stenosis in infants". N Engl J Med. 276 (15): 832–8. doi:10.1056/NEJM196704132761503. PMID 6020739.
  2. ↑ Christophe Tribouilloy, Yohann Bohbot, Sylvestre Marechaux, Nicolas Debry, Quentin Delpierre, Marcel Peltier, Momar Diouf, Michel Slama, David Messika-Zeitoun & Dan Rusinaru (2016). "Outcome Implication of Aortic Valve Area Normalized to Body Size in Asymptomatic Aortic Stenosis". Circulation. Cardiovascular imaging. 9 (11). doi:10.1161/CIRCIMAGING.116.005121. PMID 27903539. Unknown parameter |month= ignored (help)
  3. ↑ Bermejo J (2005). "The effects of hypertension on aortic valve stenosis". Heart. 91 (3): 280–2. doi:10.1136/hrt.2004.041749. PMC 1768786. PMID 15710699.
  4. ↑ J. BERGERON, W. H. ABELMANN, H. VAZQUEZ-MILAN & L. B. ELLIS (1954). "Aortic stenosis; clinical manifestations and course of the disease; review of one hundred proved cases". A.M.A. archives of internal medicine. 94 (6): 911–924. PMID 13217489. Unknown parameter |month= ignored (help)
  5. ↑ Y. J. Won, B. G. Lim, D. Chung, E. Park, H. Kim, I. O. Lee & M. H. Kong (2016). "Use of Terlipressin in an Elderly Patient With Moderate Aortic Valve Stenosis Accompanied by Episodic Atrial Fibrillation During Liver Transplantation: A Case Report". Transplantation proceedings. 48 (9): 3203–3206. doi:10.1016/j.transproceed.2016.02.082. PMID 27932181. Unknown parameter |month= ignored (help)
  6. ↑ 6.0 6.1 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)
  7. ↑ FLEMING PR (1957). "The mechanism of the pulsus bisferiens". Br Heart J. 19 (4): 519–24. PMC 503962. PMID 13471818.
  8. ↑ Blase A. Carabello & Walter J. Paulus (2009). "Aortic stenosis". Lancet (London, England). 373 (9667): 956–966. doi:10.1016/S0140-6736(09)60211-7. PMID 19232707. Unknown parameter |month= ignored (help)
  9. ↑ R. H. Swanton, B. S. Jenkins, I. A. Brooksby & M. M. Webb-Peploe (1976). "An analysis of pulsus alternans in aortic stenosis". European journal of cardiology. 4 (1): 39–47. PMID 1261578. Unknown parameter |month= ignored (help)
  10. ↑ L. Resnekov (1993). "Aortic valve stenosis. Management in children and adults". Postgraduate medicine. 93 (6): 107–110. PMID 8483818. Unknown parameter |month= ignored (help)
  11. ↑ S. J. Galloway, W. J. Casarella & P. M. Shimkin (1974). "Vascular malformations of the right colon as a cause of bleeding in patients with aortic stenosis". Radiology. 113 (1): 11–15. doi:10.1148/113.1.11. PMID 4547644. Unknown parameter |month= ignored (help)
  12. ↑ 12.0 12.1 12.2 12.3 12.4 Maganti K, Rigolin VH, Sarano ME, Bonow RO (2010). "Valvular heart disease: diagnosis and management". Mayo Clin Proc. 85 (5): 483–500. doi:10.4065/mcp.2009.0706. PMC 2861980. PMID 20435842.
  13. ↑ S. J. Galloway, W. J. Casarella & P. M. Shimkin (1974). "Vascular malformations of the right colon as a cause of bleeding in patients with aortic stenosis". Radiology. 113 (1): 11–15. doi:10.1148/113.1.11. PMID 4547644. Unknown parameter |month= ignored (help)
  14. ↑ Ilias Maglogiannis, Euripidis Loukis, Elias Zafiropoulos & Antonis Stasis (2009). "Support Vectors Machine-based identification of heart valve diseases using heart sounds". Computer methods and programs in biomedicine. 95 (1): 47–61. doi:10.1016/j.cmpb.2009.01.003. PMID 19269056. Unknown parameter |month= ignored (help)
  15. ↑ Chance M. Witt, William R. Miranda & Darrell B. Newman (2016). "The maverick heart sound". Heart (British Cardiac Society). 102 (13): 1008. doi:10.1136/heartjnl-2015-309131. PMID 26919867. Unknown parameter |month= ignored (help)
  16. ↑ Atsuko Furukawa, Yukio Abe, Makoto Ito, Chiharu Tanaka, Kazato Ito, Ryushi Komatsu, Kazuo Haze, Takahiko Naruko, Minoru Yoshiyama & Junichi Yoshikawa (2017). "Prediction of aortic stenosis-related events in patients with systolic ejection murmur using pocket-sized echocardiography". Journal of cardiology. 69 (1): 189–194. doi:10.1016/j.jjcc.2016.02.021. PMID 27012751. Unknown parameter |month= ignored (help)
  17. ↑ Jason M. Tarkin, James H. F. Rudd, David R. Jayne, Rosemary A. Rusk & Deepa Gopalan (2016). "An unusual finding in a 57-year-old woman with new onset hypertension and a diastolic murmur". Heart (British Cardiac Society). 102 (21): 1762. doi:10.1136/heartjnl-2016-309661. PMID 27411841. Unknown parameter |month= ignored (help)
  18. ↑ Lennart van Gils, Marie-Annick Clavel, Mara Vollema, Victoria Delgado, Tamim Nazif, Ernest Spitzer, Rebecca Hahn, Jeroen Bax, Martin Leon, Philippe Pibarot & Nicolas Van Mieghem (2016). "TCT-819 Clinical Outcome in Patients with Heart Failure and Moderate Aortic Stenosis". Journal of the American College of Cardiology. 68 (18S): B331–B332. doi:10.1016/j.jacc.2016.09.910. PMID 27970209. Unknown parameter |month= ignored (help)
  19. ↑ Ross J, Braunwald E (1968). "Aortic stenosis". Circulation. 38 (1 Suppl): 61–7. PMID 4894151.
  20. ↑ Michael Behnes, Siegfried Lang, Ole-A. Breithardt, Jens J. Kaden, Dariusch Haghi, Parviz Ahmad-Nejad, Elif Elmas, Christian Wolpert, Martin Borggrefe, Michael Neumaier & Martina Brueckmann (2008). "Association of NT-proBNP with severity of heart valve disease in a medical patient population presenting with acute dyspnea or peripheral edema". The Journal of heart valve disease. 17 (5): 557–565. PMID 18980090. Unknown parameter |month= ignored (help)
  21. ↑ Loay S. Kabbani, Semeret Munie, Judith Lin, Mauricio Velez, Iyad Isseh, Sara Brooks, Stephanie Leix & Alexander D. Shepard (2016). "Flow Patterns in the Carotid Arteries of Patients with Left Ventricular Assist Devices". Annals of vascular surgery. doi:10.1016/j.avsg.2016.05.119. PMID 27531092. Unknown parameter |month= ignored (help)

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