Aortic stenosis physical examination

Aortic Stenosis Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Aortic Stenosis from other Diseases
Epidemiology and Demographics
Risk Factors
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms
Physical Examination
Cardiac Stress Test
Electrocardiogram
Chest X Ray
CT
MRI
Echocardiography
Cardiac Catheterization
Aortic Valve Area
Aortic Valve Area Calculation
Treatment
General Approach
Medical Therapy
Surgery
Percutaneous Aortic Balloon Valvotomy (PABV) or Aortic Valvuloplasty
Transcatheter Aortic Valve Replacement (TAVR) TAVR vs SAVR Critical Pathway Patient Selection Imaging Evaluation Valve Types TAVR Procedure Post TAVR management AHA/ACC Guideline Recommendations
Follow Up
Prevention
Precautions and Prophylaxis
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Aortic stenosis physical examination On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Aortic stenosis physical examination All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Aortic stenosis physical examination
CDC on Aortic stenosis physical examination
Aortic stenosis physical examination in the news
Blogs on Aortic stenosis physical examination
Directions to Hospitals Treating Aortic stenosis physical examination
Risk calculators and risk factors for Aortic stenosis physical examination

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], Priyamvada Singh, MBBS [5]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [6]

Overview

Upon physical examination, a patient with suspected aortic stenosis may present with signs such as peripheral edema, congestive heart failure, a slow-rising, small volume carotid pulse, lag time between apical and carotid impulses, systolic hypertension, and a distinct systolic murmur.

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 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).

Peripheral Signs

Signs associated with peripheral edema 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

Severity of Onset Summary

Severity of aortic stenosis

Severity	mild	moderate	severe
Valve area	2.0 - 1.5	1- 1.5	<1
peak velocity (m/s)	2 -3	3-4	>4
Peak gradient (mmHg)	<35	35-65	>65
Mean gradient (mmHg)	<20	20-40	>40

References

Template:WH Template:WS