Cardiovascular · Year 1 · from Cardiovascular

Case 1: Aortic Stenosis with Classic Physical Findings

Patient Presentation

Demographics: 78-year-old male

Chief Complaint: Exertional chest pain and dyspnea for 3 months

History of Present Illness: A 78-year-old male with history of hypertension presents with progressive exertional chest pain and shortness of breath over the past 3 months. He reports symptoms when climbing one flight of stairs. He also experienced a near-syncopal episode last week while walking uphill. He denies symptoms at rest. He has a known bicuspid aortic valve diagnosed incidentally 10 years ago.

Physical Examination:

  • Vital Signs: BP 125/85 mmHg, HR 72 bpm, RR 16/min, SpO2 97% on room air
  • General: Well-appearing elderly male
  • Cardiovascular:
  • Carotid pulse: Parvus et tardus (small and slow-rising)
  • PMI: Sustained, laterally displaced
  • Auscultation: Harsh crescendo-decrescendo systolic murmur at right upper sternal border radiating to carotids
  • S2: Single or paradoxically split (delayed A2)
  • S4 gallop present
  • Lungs: Clear bilaterally

Workup

  • ECG: Left ventricular hypertrophy with strain pattern, left atrial enlargement
  • Echocardiogram:
  • Severely calcified bicuspid aortic valve
  • Aortic valve area: 0.7 cm² (severe stenosis <1.0 cm²)
  • Mean gradient: 52 mmHg (severe >40 mmHg)
  • Peak velocity: 4.8 m/s (severe >4.0 m/s)
  • LVEF: 55% with concentric LVH
  • Cardiac catheterization: Confirmed severe AS, mild CAD

Diagnosis

Severe symptomatic aortic stenosis with classic triad of angina, syncope, and dyspnea

Cardiac Cycle Correlation:

  • Systolic murmur timing: The murmur occurs during ventricular ejection (systole) as blood is forced through the stenotic aortic valve
  • Crescendo-decrescendo pattern: Reflects pressure gradient peaking in mid-systole then declining as ejection ends
  • S4 gallop: Indicates atrial contraction against stiff, hypertrophied LV (presystolic/late diastolic)
  • Parvus et tardus: Delayed upstroke and reduced amplitude of carotid pulse due to obstruction
  • Prolonged ejection time: Extends A2, causing single or paradoxically split S2
  • Wiggers diagram correlation: The stenotic valve creates a large pressure gradient between LV and aorta during ejection phase

Treatment

  1. Urgent surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR)
  2. Avoid strenuous activity until valve replacement
  3. Symptomatic patients with severe AS have poor prognosis without intervention (survival ~2-3 years with angina, ~3 years with syncope, ~1-2 years with heart failure)
  4. Beta-blockers cautiously if needed for angina (avoid vasodilators)

Clinical Image

Image Description: Echocardiogram demonstrating severely calcified aortic valve with restricted leaflet motion and continuous wave Doppler showing elevated transvalvular gradient consistent with severe aortic stenosis.

Source: Radiopaedia - Aortic stenosis License: CC BY-NC-SA 3.0 URL: https://radiopaedia.org/cases/aortic-valve-stenosis-echocardiography

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