Aortic Stenosis Diagnosis and Management

Key Diagnostic Features

• The American College of Cardiology notes that aortic stenosis produces a midsystolic murmur that is crescendo-decrescendo in configuration, heard best at the second right intercostal space with radiation to the carotid arteries 1, 2
• The combination of a midsystolic murmur, dilated ascending aorta, and small heart is consistent with valvular aortic stenosis, particularly after age 40 years 1, 2, 3, 4
• A small heart, with a left ventricle that remains relatively normal in size until late-stage disease, is characteristic of aortic stenosis 2

Physical Examination Findings to Confirm

• The American College of Cardiology recommends checking for a soft or absent A2 component of the second heart sound, or reversed splitting of S2, which denotes severe aortic stenosis 1, 2
• A parvus et tardus (weak and delayed) carotid pulse is characteristic of valvular aortic stenosis 3, 4
• An ejection click is present in most cases of aortic stenosis unless the valve is heavily calcified 3, 4
• A fourth heart sound (S4) is present if stenosis is severe 3, 4

Dynamic Auscultation Maneuvers

• The murmur intensity increases in intensity after a post-ventricular premature beat due to increased stroke volume 4
• The Valsalva maneuver decreases the murmur intensity during the strain phase, unlike hypertrophic cardiomyopathy which increases 4, 5
• Left-sided murmurs like aortic stenosis are typically louder during expiration 5

Critical Pitfall to Avoid and Immediate Next Step

• The American College of Cardiology advises against dismissing aortic stenosis as aortic sclerosis, and recommends obtaining echocardiography urgently to quantify the severity of aortic stenosis, assess valve area and gradient, evaluate left ventricular function, and measure the ascending aorta dimensions 3, 4