Classical Signs & Symptoms of Aortic Stenosis

***Quick review!!!
Symptoms: What the patient present with upon consultation.
Signs: What the doctor get from patient upon examination.

Symptoms
Symptoms and heart problems in aortic stenosis are related to the degree of narrowing of the aortic valve area. Patients with mild aortic valve narrowing may experience no symptoms. When the narrowing becomes significant (usually greater that 50% reduction in valve area), the pressure in the left ventricle increases and a pressure difference can be measured between the left ventricle and the aorta.

In 4% of the patients with aortic stenosis, the first symptom is sudden death, usually during strenuous exertion.

The major symptoms of aortic stenosis are:
• chest pain (angina)-usually 1st symptom. The pain is described as pressure below the breast bone brought on by exertion and relieved by rest. The thickened heart muscle must pump against high pressure to push blood through the narrowed aortic valve. This increases heart muscle oxygen demand in excess of the supply delivered in the blood, causing chest pain.
• fainting (syncope)- usually associated with exertion or excitement. These conditions cause relaxation of the body's blood vessels (vasodilation), lowering blood pressure. In aortic stenosis, the heart is unable to increase output to compensate for the drop in blood pressure. Therefore, blood flow to the brain is decreased, causing fainting. Fainting can also occur when cardiac output is decreased by an irregular heart beat (arrhythmia). Without effective treatment, the average life expectancy is less than three years after the onset of chest pain or syncope symptoms.
• shortness of breath (dyspnoe)- reflects the heart muscle's failure to compensate for the extreme pressure load of aortic stenosis. Shortness of breath is caused by increased pressure in the blood vessels of the lung due to the increased pressure required to fill the left ventricle. Initially, shortness of breath occurs only during activity. As the disease progresses, shortness of breath occurs at rest. Patients can find it difficult to lie flat without becoming short of breath (orthopnea). Without treatment, the average life expectancy after the onset of heart failure due to aortic stenosis is between six to 24 months.


Classical Clinical Signs
• Small and delayed pulse-absence of this finding, particularly in an elderly patient with noncompliant vasculature, does not exclude severe aortic stenosis.

• Systolic murmur-may be most easily audible in the ‘mitral area’. This may cause a mistaken diagnosis of ischaemic mitral regurgitation in a patient with severe aortic stenosis and angina. The absence of a murmur over the right clavicle can help to exclude aortic stenosis.

• Soft or absent second heart sound

• Hypotension