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In OSCE scenarios, you may be asked to perform a focused examination to determine the presence (or absence) of a certain condition. In order to do this, you need to be comfortable with the relevant basic system examination (i.e. for an aortic stenosis examination you need to be comfortable with performing a cardiovascular examination).

This guide outlines an approach to performing a focused aortic stenosis examination and is intended as a supplement to the Geeky Medics cardiovascular examination guide.


Before you start

Primary causes of aortic stenosis

1. Calcification of the aortic valves (bicuspid or tricuspid)

2. Rheumatic heart disease

During a focused examination, you should be looking out for both the signs of aortic stenosis as well as its potential causes.

 

Presentation of aortic stenosis

Aortic stenosis typically presents with the following triad of symptoms (use the mnemonic SAD to remember them):

  • Exertional Syncope
  • Angina
  • Dyspnoea

Consider asking the patient about these symptoms prior to starting your examination.


General inspection

Bedside

  • GTN spray (angina)
  • ECG readings (evidence of LV strain)
  • O2 delivery devices (dyspnoea)

The patient

  • Does the patient appear short of breath?
  • Is there any evidence of recent falls such as bruising on the face or arms (syncope)?

 

Hands

Xanthomata

  • Caused by hyperlipidaemia
  • May be associated with calcification of the valves

 

Tar staining

  • Smoking is a risk factor for cardiovascular disease and specifically for calcification of the valves

Pulses

Blood pressure

  • A narrow pulse pressure range can be found in the context of aortic stenosis

 

Carotid pulse

  • A slowly rising pulse can be felt in aortic stenosis

 

Jugular venous pressure (JVP)

  • In a focused examination for aortic stenosis, assessment of the JVP is performed to assess the presence of right heart failure secondary to left heart failure
  • This occurs as a result of excessive afterload caused by aortic stenosis
  • Remember that the JVP is considered raised if the vertical height is more than 4 cm above the sternal angle.

Face

Corneal arcus

  • A sign of hypercholesterolaemia
  • Increases clinical suspicion of valve calcification

 

Xanthelasma

  • A sign of hypercholesterolaemia
  • Increases clinical suspicion of valve calcification

 

Malar flush

  • Red discolouration of the cheeks
  • A sign of mitral stenosis (rheumatic heart disease can cause stenosis of both the mitral and aortic valve and therefore this is an important clinical sign to be aware of)

Chest inspection

It is important to perform a close inspection of the chest to identify any associated valvular pathologies as well as scars from previous thoracic surgery.

Scars

Thoracotomy – minimally invasive valve surgery

Sternotomy – coronary artery bypass graft (CABG) / valve surgery

Top tip: If you see a sternotomy scar you should inspect the legs for signs of surgical scars from previous vein harvesting. If a scar is present on only one leg, this can lead to unilateral peripheral oedema.

  • Sternotomy scar + graft scar on the legs
    • Previous CABG likely
  • Sternotomy scar but no graft scar on the legs
    • More likely to have had a valve replacement (has this patient already been treated for aortic stenosis?)

 

Visible pulsations

Forceful apex beat may be visible:

  • Classically caused by ventricular hypertrophy
  • This may occur secondary to the excessive afterload caused by aortic stenosis

Palpation

Apex beat

  • The apex beat in aortic stenosis is described as heaving and non-displaced

 

Thrills

  • In the context of aortic stenosis, a systolic thrill may be felt over the aortic region and carotids

 

Levine Murmur Grading Scale (simplified)

Grade 1 – very faint murmur which is only audible during prolonged auscultation

Grade 2 – faint murmur, immediately audible with a stethoscope

Grade 3 – loud murmur with NO thrill

Grade 4 – loud murmur WITH a thrill

Grade 5 – loud murmur WITH a thrill, heard with only half of the stethoscope touching the chest

Grade 6 – loud murmur WITH a thrill, heard WITHOUT the stethoscope touching the chest

Top tip: Never describe a murmur as grade 1 or 2 in OSCE examinations as it is commonly accepted that only expert cardiologists can detect these murmurs! The grading system can be made easier by remembering that grade 4 and above requires the presence of a thrill.


Auscultation

  • An ejection systolic murmur is heard in aortic stenosis
  • The ejection systolic murmur in aortic stenosis is often heard loudest over the aortic valve (2nd intercostal space, right sternal edge)
  • The murmur is described as having a crescendo-decrescendo’ quality (diamond shaped on a phonogram)
  • The murmur can radiate to the carotids and this is heard on auscultation over the carotids with the patient holding their breath to eliminate laryngeal air noise
  • If the stenosis is severe, a quiet second heart sound and possibly a fourth heart sound may be heard

 

Heart sounds - aortic stenosis

Normal heart sounds and aortic stenosis murmur 1

 


Summarising findings

If a murmur is heard it is important to have a systematic way in which to summarise this back to the examiner. Key questions to ask yourself are shown below and the answers to these questions can be used to generate a systematic format in which to present your findings. These questions apply to any murmur with the answers below being specific to the murmur heard as a result of aortic stenosis.

 

What type of murmur did I hear? Was it systolic or diastolic?

  • An ejection systolic murmur

 

What grade was the murmur?

  • Use the Levine Grading Scale

 

Where did I hear the murmur loudest?

  • Tends to be heard loudest in the aortic region

 

Did the murmur radiate?

  • Classically radiates to the carotids

 

Did the murmur have a specific quality associated with it?

  • Described as having a ‘crescendo-decrescendo’ quality (think of the diamond shape)

 

Are there any signs which could confirm my suspicion of the type of valvular disease?

  • e.g. narrow pulse pressure, heaving apex beat

 

Example summary

“Today I performed a focused cardiovascular examination on this 64-year-old gentleman to assess for the presence of aortic stenosis. On general inspection, he appeared comfortable at rest and was not in any visible pain or discomfort. On palpation, there were no palpable heaves. On auscultation, I could hear the first and second heart sounds. An ejection systolic murmur of grade 3 intensity could be heard loudest in the aortic region. This radiated to the carotids and had a crescendo-decrescendo quality to it. With the additional findings of a narrow pulse pressure and a heaving apex beat which was not displaced, I suspect this murmur is the result of aortic stenosis. To complete my examination I would consider further investigations such as an ECG, relevant blood tests and echocardiography.”

 

Aortic stenosis clinical signs summary 

Aortic stenosis summary table


References

1. By Madhero88 [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], from Wikimedia Commons

2. Ruthven A. Essential Examination. 3rd Edition. Scion Publishing Ltd, 2016; 2016


 

Editor

Andrew Gowland

 


 

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