What type of murmur is a client with aortic stenosis most likely to present with?

Aortic Stenosis Presents with a Mid-Systolic Murmur

A client with aortic stenosis most likely presents with a mid-systolic murmur, not a diastolic murmur and S3 gallop or right ventricular hypertrophy. 1

Characteristic Murmur of Aortic Stenosis

Aortic stenosis (AS) produces a distinctive murmur with the following characteristics:

• Timing: Mid-systolic (ejection) murmur
• Location: Best heard at the second right intercostal space (aortic area)
• Radiation: Often radiates to the carotid arteries
• Quality: Harsh, crescendo-decrescendo configuration
• Intensity: Variable, depending on severity and cardiac output

The European Society of Cardiology guidelines specifically state: "The characteristic systolic murmur draws attention and guides further diagnostic work-up" when discussing aortic stenosis 1. This is corroborated by the ACC/AHA guidelines which describe the typical findings in aortic stenosis 1.

Distinguishing Features and Associated Findings

Several additional findings can help identify aortic stenosis:

• Carotid pulse: May demonstrate parvus et tardus (slow-rising, diminished) quality in severe AS, though this may be absent in elderly patients 1
• Second heart sound (S2): Soft or absent A2 component or paradoxical splitting in severe AS 1
• Ejection click: May be present with bicuspid aortic valve, unless the valve is heavily calcified 1
• Response to maneuvers: The murmur increases with exercise and during the initial phase after amyl nitrite inhalation (due to increased stroke volume) 1

What Aortic Stenosis is NOT Associated With

• Diastolic murmur: Primarily associated with aortic regurgitation, mitral stenosis, or tricuspid stenosis, not aortic stenosis 1, 2
• S3 gallop: More commonly associated with heart failure and volume overload conditions rather than aortic stenosis 1
• Right ventricular hypertrophy: Primarily associated with right-sided heart conditions (pulmonary hypertension, pulmonic stenosis), whereas aortic stenosis primarily affects the left ventricle 1

Clinical Significance

Aortic stenosis is the most prevalent valvular heart disease in developed countries 3, 4. Proper identification of the characteristic murmur is crucial because:

1. Symptomatic severe AS is universally fatal if left untreated 4
2. Timely intervention can restore normal life expectancy 4
3. The murmur may occasionally be faint, leading to missed diagnosis 1, 5

Potential Pitfalls in Diagnosis

• Classical signs of severe AS may be unreliable, especially in elderly patients 5
• The murmur may be soft in patients with heart failure and reduced cardiac output 1
• Coexisting conditions may mask or modify the typical murmur characteristics
• Relying solely on murmur intensity can be misleading; echocardiography is essential for definitive diagnosis 1, 6

Diagnostic Approach

When a mid-systolic murmur suggestive of AS is detected:

1. Assess for associated symptoms (syncope, angina, heart failure) which indicate more urgent evaluation 1
2. Perform dynamic auscultation maneuvers to help differentiate from other causes 1
3. Obtain echocardiography to confirm diagnosis and assess severity 1
4. Consider additional imaging if the ascending aorta is not well visualized 1

Remember that while the murmur characteristics are helpful for initial detection, echocardiography remains the definitive diagnostic tool for confirming aortic stenosis and determining its severity.