Aortic stenosis physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editors-In-Chief: Claudia P. Hochberg, M.D. [2]; Abdul-Rahman Arabi, M.D. [3]; Keri Shafer, M.D. [4]

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. 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 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).

An easily heard systolic, crescendo-decrescendo (i.e. 'ejection') murmur is heard loudest at the upper right sternal border, and radiates to the 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.

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 be manifest.

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.

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).

Murmur in Aortic stenosis <youtube v=O4bFK3CGLh8/>

Peripheral Signs Include

• a slow-rising, small volume carotid pulse
• narrowed pulse pressure
• sustained, thrusting apex beat which is usually not displaced unless the stenosis is severe

References

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