Aortic stenosis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Mohammed A. Sbeih, M.D. [2]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [3]

Overview

Aortic stenosis must be differentiated from other cardiac or pulmonary causes of dyspnea, weakness, and dizziness. Furthermore, when left ventricular outflow tract obstruction is present, it is critical to identify whether the obstruction is subvalvular, valvular or supravalvular and whether there is hypertrophic Cardiomyopathy (HOCM) or not.

Differential Diagnosis

Differentiating Aortic Stenosis from Pulmonary Causes of Dyspnea

Aortic stenosis can be differentiated from pulmonary causes of dyspnea by the presence of:

• A narrow pulse pressure
• A harsh late-peaking systolic murmur heard best at the right second intercostal space with radiation to the carotid arteries
• A delayed slow-rising carotid upstroke (pulsus parvus et tardus)
• Signs of heart failure on examination

Differentiating Aortic Stenosis from Aortic Sclerosis

While a murmur may be heard in aortic sclerosis, there is no fusion of the commisures and no significant obstruction to antegrade blood flow across the aortic valve. As a result, the S2 is normal in aortic sclerosis and the carotid upstroke is normal (i.e. pulsus parvus et tardus is absent).

Differentiating Aortic Stenosis from Mitral Regurgitation

The murmur of aortic stenosis is harsh and best heard at the right second intercostal space while the murmur of mitral regurgitation is blowing, soft and best heard at the apex.

Differentiating Aortic Stenosis from Hypertrophic Obstructive Cardiomyopathy

In HOCM the murmur is dynamic and varies with maneuvers. Moreover, there is a bifid or spoke and dome pattern of the carotid upstroke.

Differentiating Valvular Aortic Stenosis from Subvalvular Aortic Stenosis

Aortic insufficiency is more often present with subvalvular aortic stenosis (in 50% to 75% of cases). Symptoms associated with subvalvular aortic stenosis begin earlier in life (in childhood or adolescence) than symptoms associated with valvular aortic stenosis.

Differentiating Valvular Aortic Stenosis from Supravalvular Aortic Stenosis

Supravalvular aortic stenosis is an uncommon congenital anomaly caused by a narrowing in the ascending aorta or by the presence of a fibrous diaphragm just above the aortic valve. It presents in early adulthood. Although the aortic valve is not stenotic, doppler shows an increased pressure gradient. 50% of patients with supravalvular aortic stenosis have a characteristically greater pulse and systolic blood pressure in the right carotid and brachial arteries than in the left. The systolic murmur is maximal below the right clavicle and radiates primarily to the right carotid artery. There is not an ejection click nor a diastolic murmur.