What is the initial step in managing a patient with an aortic murmur?

Initial Management of Aortic Murmur

The initial step is performing a focused cardiovascular physical examination to characterize the murmur and determine whether immediate echocardiography is indicated. 1, 2, 3

Immediate Physical Examination Priorities

Characterize the murmur timing and quality:

• Diastolic murmurs are virtually always pathologic and require immediate echocardiography regardless of intensity or associated symptoms 1, 2, 3
• Listen with the patient leaning forward, holding breath after expiration, at the left sternal border for aortic regurgitation 2
• Note that aortic regurgitation commonly presents with a systolic murmur (86% of moderate AR cases) rather than the classic diastolic murmur when examined by non-cardiologists 4

Assess the second heart sound (S2):

• A normally split S2 reliably excludes severe aortic stenosis 5, 3
• A single or soft S2 suggests severe aortic stenosis due to valve immobility 5, 3

Evaluate peripheral signs:

• Check for exaggerated arterial pulsations and wide pulse pressure (suggests chronic AR) 1, 2
• Assess carotid pulse character for parvus et tardus (delayed, dampened upstroke in severe AS), though this may be absent in elderly patients due to arterial stiffening 1, 3

Indications for Immediate Echocardiography

Proceed directly to echocardiography if ANY of the following are present:

Murmur characteristics requiring imaging: 1, 2, 3

• Any diastolic murmur
• Continuous murmurs
• Holosystolic or late systolic murmurs
• Grade 3/6 or louder systolic murmurs
• Murmurs radiating to neck or back
• Murmurs with ejection clicks

Associated symptoms: 1, 2, 3

• Syncope
• Angina or chest pain
• Heart failure symptoms (dyspnea, orthopnea, edema)
• History of thromboembolism

Abnormal examination findings: 1, 3

• Single or paradoxically split S2
• Parvus et tardus carotid pulse
• Displaced left ventricular impulse

When Echocardiography May Be Deferred

Only in highly selected cases: 1, 3

• Asymptomatic young adults with grade 2/6 or less midsystolic murmurs
• Murmur heard only along left sternal border
• Normal S2 splitting present
• No other cardiac physical findings
• Normal ECG and chest X-ray if already obtained

Special consideration for elderly patients:

• Many elderly patients have grade 1-2 midsystolic murmurs from aortic sclerosis, but echocardiography is frequently necessary to distinguish this from true aortic stenosis 1, 3
• Classic signs of severe AS may be absent in elderly patients, making echocardiography essential 3

Ancillary Testing

ECG and chest X-ray provide supportive information: 1

• Absence of ventricular hypertrophy, atrial enlargement, or conduction abnormalities provides useful negative information
• Abnormal findings (ventricular hypertrophy, prior infarction, chamber enlargement) mandate echocardiography
• However, these tests should not delay echocardiography when indicated 3

Critical Pitfalls to Avoid

Do not rely solely on the presence or absence of a diastolic murmur to diagnose or exclude aortic regurgitation—systolic murmurs are more common presentations in routine screening 4

Do not assume a soft murmur in an elderly patient is benign aortic sclerosis without echocardiographic confirmation, as severe AS can present with atypical findings in this population 3

Do not miss acute aortic regurgitation, which presents with attenuated peripheral signs despite poor hemodynamic tolerance 1, 2

Always assess the aortic root and ascending aorta during echocardiography, as AR is frequently associated with aortic pathology requiring separate management 1, 2