Symptoms of aortic stenosis

Angina, syncope and features of heart failure are the important symptoms of aortic stenosis which correlate with survival. The median survival with these symptoms are five, three and two years respectively. Angina occurs in aortic stenosis because of a demand supply mismatch in a hypertrophied left ventricle. Syncope is related to exercise and is due to a relatively fixed cardiac output in the face of systemic vasodilatation which occurs with exercise. Since the cardiac output can hardly increase with exercise in severe aortic stenosis, cerebral hypoperfusion and syncope results.

Pulse in aortic stenosis

The characteristic pulse in severe aortic stenosis is slow rising low volume pulse known as pulsus parvus et tardus. A bisferiens pulse is noted in a combination of aortic stenosis and aortic regurgitation. Bisferiens pulse has two peaks in systole and is more likely to occur in free aortic regurgitation or dominant aortic regurgitation rather than in dominant aortic stenosis.

Blood pressure in severe aortic stenosis

The systolic pressure is low and the pulse pressure is narrow in severe aortic stenosis.

Apex beat in aortic stenosis

The apex is formed by the left ventricle in aortic stenosis and it is a heaving (sustained and forceful) apex in severe aortic stenosis.

Heart sounds in aortic stenosis

In severe aortic stenosis, the aortic component is soft and delayed, sometimes even a paradoxical split may occur. Fourth heart sound may be audible due to the forceful atrial contraction needed to improve the filling of a hypertrophied left ventricle. Third heart sound can be heard in left ventricular failure.

Thrill and murmur in aortic stenosis

A systolic thrill is felt in severe aortic stenosis in the aortic area and over the carotids. A systolic thrill can also occur in lower degrees of aortic stenosis if there is associated aortic regurgitation. The ejection systolic murmur is harsh, loud, long, late peaking and best heard in aortic area and conducted to the carotids in severe aortic stenosis. The murmur may become less audible if the left ventricle fails and hence severe aortic stenosis is an important differential diagnosis of dilated cardiomyopathy. When the left ventricular function improves with treatment or inotropic support, the murmur becomes more prominent in severe aortic stenosis with heart failure. In aortic stenosis of the elderly, the murmur of aortic stenosis is harsh in the aortic area and more musical in the mitral area resembling associated mitral regurgitation. This phenomenon is known as Gallavardin’s dissociation. The harsh murmur in the aortic area is due to turbulent flow across the stenotic aortic valve and the musical murmur in the mitral area is supposed to be due to the vibration of the left ventricular outflow tract.