The AR murmur has to be differentiated from other conditions that could associate basal diastolic murmurs: Pulmonic regurgitation is indistinguishable in location, timing and quality from the AR murmur, so the distinction is made only by precordial palpation and the lack or presence of peripheral signs.
The following clinical findings suggest a severe AR : 1. A Holodiastolic Murmur The duration and quality of murmur are directly proportional to the severity of AR. Marked Peripheral Signs There are only few data about the predictive value of peripheral signs in diagnosing the severity of AR. The Austin Flint Murmur The murmur typically begins in mid-diastole, often has a presystolic accentuation, and terminates at the end of diastole. Signs of LV Dilation and Dysfunction The systolic apical impulse is laterally and inferiorly displaced, the intensity of the S1 is decreased due to the elevated LVED pressure and the early closure of the mitral valve and a protodiastolic gallop S3 gallop is usually heard at the apex.
Conclusion If we are aware of its limitations and strengths and we succeed in keeping our expertise and proficiency in cardiac auscultation, then clinical examination remains a valuable and cost-effective tool that often enables a rapid, integrative, accurate and patient-orientated diagnosis of aortic valve disease.
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The intensity of the murmur reflects the velocity and turbulence of blood flow across the valve. Difficult to be assessed clinically, especially in patients with tachycardia, atrial fibrillation, low grade murmur.
The aortic cusps are immobile, so the A2 is faint or even not audible. S2 is increased in associated pulmonary hypertension, other valve heart diseases, hypertensive heart. In LV dysfunction the ejection time does not correlate to the AV area. It occurs at the moment of maximal opening of the AV, when the valve is bicuspid, still flexible.
The phenomenon known as "pulsus parvus et tardus" refers to a weak parvus and delayed tardus carotid upstroke. It is important to note that in some elderly individuals the carotids may be stiff due to calcification, which may falsely normalize the carotid upstroke.
To assess for "tardus," auscultate the patient's S2 heart sound while palpating their carotid upstroke. The S2 and carotid upstroke should occur almost simultaneously. If the carotid upstroke comes significantly after the S2 heart sound, "tardus" is present indicating severe aortic stenosis.
Other physical exam findings in patients with aortic stenosis include those of both right and left heart failure. Back to Healio. Topic Reviews A-Z Save. Aortic Stenosis - Physical Exam Auscultation of the heart in patients with aortic stenosis can be very helpful in both the diagnosis and determining the severity of disease.
Read more about systole. It may be subclinical, manifesting only as a murmur, but can still cause unexpected death with little warning after symptoms develop. Recent studies have highlighted the unreliability of the classical clinical signs of severe aortic stenosis, leading to concern that some patients may not be referred appropriately for echocardiography.
Here, we review the evidence for the accuracy of each sign. We suggest that the assessment of the patient with a systolic murmur should be reappraised, and offer guidelines toward improving the recognition of aortic stenosis in the community. Aortic stenosis is common. All of these signs, however, are unreliable. Almost all patients with moderate or severe aortic stenosis have an audible systolic murmur.
This may cause a mistaken diagnosis of ischaemic mitral regurgitation in a patient with severe aortic stenosis and angina.
The absence of a murmur over the right clavicle can help to exclude aortic stenosis. Etchells et al. Why do these observations differ from the clinical findings traditionally expected in aortic stenosis? This has chiefly been explained by the changing aetiology and demographic profile of the condition, now largely degenerative and prevalent in the elderly. In , all cases were judged to be rheumatic on pathological examination, and the average age at death was 55 to 65 years.
Signs may vary according to flow rate across the aortic valve with changing heart rate and cardiac output and concomitant or secondary left ventricular dysfunction will result in a shorter and quieter systolic murmur.
Are studies that employ consultant cardiologists applicable to general and primary care physicians? Although systemic blood pressure can be reliably measured, cardiac auscultation and carotid palpation are highly subjective and poorly reproducible. No studies have compared the auscultatory skills of consultant cardiologists against those of junior doctors, and a retrospective analysis of patients referred for echocardiography by general physicians showed that the auscultatory findings were not predictive of echocardiographic abnormalities.
If the clinical signs of aortic stenosis are unreliable, should every patient with a systolic murmur be selected for echocardiography? Severe aortic stenosis is common, but may be asymptomatic. A small number of patients with aortic stenosis present late with overt symptoms and signs of cardiac failure, 18 which may be precipitated by another clinical event such as a chest infection.
It is therefore important to be aware of the possibility of aortic stenosis, and we suggest that auscultation at the apex and right parasternal position should be performed in every patient aged over 70 years who presents with such symptoms.
We would further advocate screening all patients above 70 if they visit a general practitioner or clinic even in the absence of cardiac symptoms, because the sharp mortality rise after symptom onset and the length of surgical waiting lists makes advance awareness of severe aortic stenosis important.
Echocardiography should be requested in patients with a loud murmur or any suggestion of exertional symptoms. It is vital to be aware that supervening heart failure causes a fall in the grade of murmur. All patients with clinical signs of heart failure and a murmur require echocardiography. This must be performed before starting treatment with an ACE inhibitor.
On the other hand, systolic murmurs are common, occurring in up to half of elderly patients, and mild aortic stenosis may take 15 or more years to progress to severe. Aortic stenosis is common in the elderly and potentially fatal soon after or even before the onset of noticeable symptoms. The classical signs of severe aortic stenosis are often absent, and, in particular, systemic hypertension is common.
Every patient aged over 70 years should be auscultated routinely if they visit their general practitioner, and, if a systolic murmur is detected, questioned carefully for exertional symptoms. For all other patients, a routine echocardiogram should be requested to exclude significant aortic stenosis.
Address correspondence to Dr P. Prevalence of aortic valve abnormalities in the elderly: an echocardiographic sample of a random population. J Am Coll Cardiol ; 21 : —5.
The natural history of adults with asymptomatic, haemodynamically significant aortic stenosis. J Am Coll Cardiol ; 15 : — Horstkotte D, Loogen F. The natural history of aortic valve stenosis. Eur Heart J ; 9 Suppl E : 57 — Mortality and worsening prognostic profile during waiting time for valve replacement in aortic stenosis.
Thoracic Cardiovasc Surg ; 44 : — Isolated valvular aortic stenosis. Acta Med Scand ; : 61 —4.
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