Aortic Stenosis Diagnosis and Management

Clinical Presentation and Diagnosis

A harsh systolic murmur at the second intercostal space that radiates to the carotid arteries is the classic presentation of aortic stenosis, as recommended by the American Heart Association 2
Syncope in the context of a systolic murmur strongly suggests severe aortic stenosis, indicating hemodynamically significant obstruction to left ventricular outflow, according to the American College of Cardiology 1
Carotid bruits can be distinguished from aortic stenosis murmurs as they disappear with bilateral shoulder hyperextension and are typically heard in the supraclavicular region or anterior neck, not at the second intercostal space, as noted by the American Heart Association 3, 4
The presence of syncope makes an innocent murmur extremely unlikely, as stated by the American College of Cardiology 1
Hypertrophic cardiomyopathy can be distinguished from aortic stenosis as the maximal intensity is at the fourth left intercostal space rather than the second intercostal space, according to the American Heart Association 5

Urgent echocardiography is mandatory for any murmur with syncope, as recommended by the American College of Cardiology 1
Syncope indicates potentially severe aortic stenosis with average survival of only 3 years after syncope onset without surgical intervention, as noted by the American Heart Association 1
Classic physical examination signs may be unreliable in elderly patients for determining severity, according to the American Geriatrics Society 6
The only reliable physical finding to exclude severe aortic stenosis is a normally split S2, as stated by the American College of Cardiology 6
If S2 is single or paradoxically split, severe aortic stenosis is likely present, according to the American Heart Association 1, 6