Review Question - QID 100724

A systolic crescendo-decrescendo ("ejection") murmur that radiates to the carotid arteries is typical in aortic stenosis.

Aortic stenosis is a narrowing of the aortic valve that can arise from congenital abnormalities (unicuspid or bicuspid valve), age-related atherosclerotic calcification, and rheumatic heart disease. Individuals with unicuspid valves usually present in childhood and those with bicuspid, in middle age, while those with other causes are usually > 65. Symptoms only occur in more advanced stages and include angina, fatigue, and dyspnea.

Grimard and Larson review the diagnosis and management of aortic stenosis. This condition creates increased afterload in the heart, which leads to atrial augmentation and left ventricular hypertrophy. As the disease progresses, though, these compensatory mechanisms become inadequate. They note that once a patient is symptomatic average survival is 2-3 years without intervention.

Nishimura et al. discuss the management of aortic stenosis. Transthoracic echocardiogram is performed to stage the severity of the disease, which in turn dictates treatment. Staging (A-D) is determined by a combination of aortic jet velocity and mean transvalvular pressure gradient. Aortic valve replacement is generally considered for those with stage C or D disease.

Illustration A is a phonocardiogram of heart sounds in normal and abnormal hearts. Illustration B depicts how different areas of auscultation correspond with different parts of the heart.

Incorrect Answers:
Answer 1: The S3 heart sound is not present aortic stenosis. It can be normal up until age 35-40; after this age, it is associated with ventricular dysfunction or an increase in volume load.
Answer 3: Radiation of a murmur to the axilla is typical of mitral valve regurgitation.
Answers 4-5: Asymmetric ventricular hypertrophy and double pulsation of the carotid pulse may occur in hypertrophic cardiomyopathy. Hypertrophic obstructive cardiomyopathy could also present with asymmetric septal hypertrophy and a murmur that radiates to the carotids, though this is a less likely diagnosis epidemiologically in this patient. Aortic stenosis could present with asymmetric septal hypertrophy; however, the murmur that radiates to the carotids is a more specific and sensitive finding.