Aortic stenosis physical examination

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Aortic Stenosis Microchapters

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

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

Neck

  • Pulsus parvus et tardus which is a low volume, slow rising pulse with a gradual upstroke and may be present secondary to prolongation of the ejection phase.[1]
  • Pulsus bisferiens may be present in patients with mixed aortic stenosis and aortic regurgitation
  • Delayed carotid upstroke (apical-carotid delay): There 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).
  • Systolic thrill may be palpated at the right second intercostal space, at the base of the heart, in the jugular notch, and along carotid arteries.
  • Murmur: The systolic ejection murmur of aortic stenosis may be transmitted bilaterally to the carotid arteries

Lungs

Heart

  • Apical impulse:
  • Heart Sounds:
  • The S2 tends to become quiet or absent with increasing severity of aortic stenosis, secondary to an increase in valve calcification preventing it from "snapping" shut, and the valve no longer produces a sharp, crisp, loud closing sound.
  • Additionally, a reverse S2 spilt may be observed with aortic stenosis, wherein the S2 split widens during the expiratory phase.
  • Murmur:
  • Crescendo-decrescendo type of ejection systolic murmur
  • Best heard at the upper right sternal border
  • Bilateral radiation to the carotid arteries
  • Murmur increases with squatting
  • Murmur 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.
  • Ejection clicks may be absent in severely calcified aortic stenosis due to the rigid valve cusps.

Extremeties

Relative Value of Various Physical Examination Findngs

A meta analysis[1] 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 to 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).

Murmur in Aortic Stenosis

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References

  1. 1.0 1.1 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)


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