Q. What are the Physical Signs of aortic stenosis?

Typically the carotid pulse in severe aortic stenosis is delayed (pulsus tardus). It is also decreased in amplitude (pulses parvus) when cardiac decompensation occurs. This pulse is fairly specific for severe aortic stenosis. However, patients with low cardiac output and mild stenosis will have a low volume pulse that is normal in timing.

In patients with atherosclerotic vessels carotid upstroke may be brisk even in severe aortic stenosis. A detectable time gap between the apical pulse and carotid pulse suggests prolonged ejection time of severe aortic stenosis. Wide pulse pressure in the presence of other findings of severe aortic stenosis suggests associated aortic regurgitation. Also wide pulse pressure with normal diastolic pressure is fairly common in elderly patients with concomitant hypertensive vascular disease.

Typically apical impulse is forcible and sustained and with decompensation of left ventricle it is displaced. A palpable S4 is common in severe aortic stenosis. Absence of a valvular ejection click in children should make one suspect the diagnosis of non valvular aortic stenosis. Usually S2 is single due to muffled A2 . If the valve is pliable with less extent of calcification, it may produce paradoxical split in a patient with severe valvular aortic stenosis. Typically the murmur of valvular aortic stenosis starts after S1, is crescendo decrescendo ejection systolic murmur with maximum intensity at second right inter costal space and radiates to carotids. A grade I murmur in the absence of decompensation suggests mild lesion while the same in a patient with severe decompensation should not make one eliminate aortic stenosis as a cause of decompensation.

A grade IV murmur almost always suggests severe aortic stenosis. In children and elderly selective conduction of high frequency sounds to apical area may give risk to cooing murmur at apex (Gallavardin phenomenon). However, the intensity of murmur may vary with cardiac output, chest valve thickness, emphysema and direction of turbulent jet. A late peaking loud grade IV murmur is very specific to severe aortic stenosis.