Aortic stenosis physical examination


 * Mohammed A. Sbeih, M.D. [mailto:msbeih@perfuse.org]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [mailto:kfeeney@perfuse.org]

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.

Vitals

 * Narrow pulse pressure: The systolic pressure may decrease and narrow pulse pressure may be present.
 * The rate and rhythm are usually regular, but late in the course of aortic stenosis, the left atrium dilates and atrial fibrillation may develop in which case the pulse is irregularly irregular.

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.
 * 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

 * Pulmonary rales may be present in the patient who develops congestive heart failure

Heart

 * Apical impulse:
 * Left ventricular hypertrophy secondary to aortic stenosis can produce a heave or lift (palpable impulse) and a laterally displaced apical impulse
 * In the left lateral recumbent position, a double apical impulse if present is characteristic of hypertrophic obstructive cardiomyopathy instead of aortic stenosis


 * 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.


 * S4: Secondary to the sustained increase in left ventricular pressure, over time the left ventricle may hypertrophy, resulting in diastolic dysfunction and consequent production of an S4 (due to forceful atrial contraction against the stiff ventricle). With continued increase in ventricular pressure, ventricular dilatation ensues, and an S3 may be auscultated.


 * 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.


 * 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. 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 tow valvular diseases coexist.

Extremeties

 * Peripheral edema may be present in a patient who subsequently develops congestive heart failure

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:


 * 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).