What are the clinical signs of aortic stenosis?

Clinical Signs of Aortic Stenosis

The classic clinical signs of aortic stenosis include a harsh systolic ejection murmur radiating to the carotid arteries, diminished carotid upstroke, and symptoms of angina, dyspnea, and syncope that indicate disease progression and significantly worsened prognosis. 1

Cardiac Auscultation Findings

• A harsh systolic ejection murmur best heard at the right upper sternal border (aortic area) with radiation to the carotid arteries 1
• A palpable thrill may be present over the aortic area in severe stenosis 1
• Diminished or absent second heart sound (A2) due to reduced valve mobility in severe cases 1
• A late-peaking systolic murmur correlates with increasing severity of stenosis 1
• Slow-rising, diminished carotid pulse (pulsus parvus et tardus) is characteristic of severe aortic stenosis 1

Cardinal Symptoms

• Dyspnea on exertion (often the first symptom to appear) indicates heart failure development 1, 2
• Angina pectoris occurs due to increased oxygen demand from LV hypertrophy and reduced coronary reserve 1, 2
• Syncope or near-syncope, particularly with exertion, due to inability to increase cardiac output in the face of peripheral vasodilation 1

ECG and Other Clinical Findings

• Left ventricular hypertrophy with or without strain pattern on ECG 1
• Narrow pulse pressure in advanced disease 1
• Signs of heart failure including peripheral edema, pulmonary rales, and elevated jugular venous pressure in late stages 1, 2

Prognostic Significance of Symptoms

• Asymptomatic patients with severe aortic stenosis have a relatively good prognosis with low risk of sudden cardiac death (3-5%) 1
• Once symptoms develop, prognosis worsens dramatically with mortality rates of 25% at 1 year and 50% at 2 years if left untreated 1, 2
• Average survival after symptom onset is approximately 2 years for heart failure, 3 years after syncope, and 5 years after angina if valve replacement is not performed 1, 2

Clinical Pitfalls and Caveats

• The murmur intensity may paradoxically decrease in very severe aortic stenosis with reduced cardiac output 1
• Coexisting aortic regurgitation may be present, characterized by an early diastolic murmur 1
• Symptoms may be attributed to comorbidities (especially in elderly patients), masking the diagnosis of severe aortic stenosis 3
• The classic triad of symptoms (angina, syncope, dyspnea) typically appears late in the disease course when left ventricular dysfunction has already developed 1, 2
• Echocardiography is essential for diagnosis, but clinical assessment remains crucial as a "pre-test probability" guide for interpreting imaging results 1
• Exercise testing may unmask symptoms in apparently asymptomatic patients and carries prognostic significance 1, 2

Special Considerations

• In elderly patients, the murmur may be softer due to calcification limiting valve excursion 1
• Patients with low cardiac output states may have severe aortic stenosis despite lower gradients (low-flow, low-gradient severe AS) 4
• Restriction of physical activity is recommended in moderate to severe aortic stenosis to reduce risk of sudden cardiac death 1
• The presence of an ejection systolic murmur in the aortic area warrants echocardiographic evaluation, especially when accompanied by two or more features suggesting significant aortic stenosis 1