Like most mornings in general practice, this one has been busy. You’ve seen many patients already, including a mum with postnatal depression, a tradie recovering from a workplace injury, and several toddlers with hand foot and mouth. You’ve also developed an enhanced primary care plan to help one patient gain better control of her type 2 diabetes. And you’re concerned about that four-year-old who’s stopped bearing weight on her right leg.
Now, you’re looking at a 60-year-old man complaining of breathlessness. He’s carrying a few extra kilos so that could explain it. Respiratory issues are certainly a possibility but it could be something else. You’re wondering if his heart’s struggling.
Patients with aortic stenosis may present with shortness of breath on exertion and an alert GP will consider potential cardiac causes as well as respiratory ones.
Symptoms of an Aortic Stenosis Murmur
The patient may not mention any other symptoms, often because they’ve been of gradual onset and that patient has adapted by dropping their activity levels over time. So, ask your patient some probing questions.
There are certain red flags that signal aortic stenosis. The classic symptom triad is:
- Exertional dyspnea (breathlessness during exercise)
- Angina (chest pain or discomfort)
- Presyncope or syncope (dizziness or fainting).
Patients may also complain of fatigue, have swollen feet or ankles or an irregular heartbeat.
Such symptoms, in isolation or combination, can indicate aortic stenosis.
Identifying an Aortic Stenosis Murmur
Once you’ve reviewed the patient’s signs and symptoms and explored their medical history, it’s time for a physical examination.
Auscultate for an aortic valve murmur. This is best heard at the right sternal border in the second intercostal space. It may radiate bilaterally to the carotid arteries — sit the patient upright for the best opportunity to hear this.
The two major sounds heard in a healthy heart are S1 and S2. S1’s ‘lub’ sound is caused by turbulence when the mitral and tricuspid valves close. During systole, the ventricles contract and push blood through the aortic valve. S2’s ‘dub’ sound results from the closure of the aortic and pulmonic valves and marks the end of systole.
If your patient has a narrowed aortic valve, then you may hear an aortic stenosis murmur between S1 and S2. The narrowed aortic valve slows the flow of blood and causes greater turbulence. That’s heard as an ejection systolic murmur or click crescendo-decrescendo murmur between S1 and S2.
If you hear a systolic murmur then refer the patient to a cardiologist for further investigations and management.
Once a cardiologist diagnoses aortic stenosis, they will recommend one of three main treatment options:
- Surgical aortic valve replacement (SAVR)
- Transcatheter aortic valve implantation (TAVI)
- Balloon valvuloplasty.
Aortic Stenosis Prognosis
Without treatment, the prognosis is bleak. About 50% of patients with severe aortic stenosis will die within two years if their aortic valve is not replaced. This prognosis is worse than most cancers.
That emphasises the importance of spotting the signs of aortic stenosis in general practice so that patients can be referred to a cardiologist for active management of their condition.