Clinical Features

The classic triad is dyspnea, chest pain, and syncope. Exercise may induce acute symptoms. Symptoms appear late in the course of the disease. In active persons, the symptoms appear more rapidly. Dyspnea is usually the first symptom, followed by paroxysmal nocturnal dyspnea, syncope on exertion, angina, and myocardial infarction. Atrial fibrillation is less common than in mitral disease, but 10 percent of patients have atrial fibrillation at time of surgery. With isolated aortic stenosis, endocarditis occurs in only 2 percent of patients.

The most common signs include a pulse of small amplitude. The carotid pulse can be most accurately assessed and is found to have a slow rate of increase. Blood pressure is normal or low, with a narrow pulse pressure. LVH is common. There is paradoxic splitting of S 2, and S3 and S4 are commonly present. Classically, there is a harsh systolic ejection murmur that is best heard in the second right intercostal space and that radiates to the right carotid artery. Brachioradial delay is an important finding in aortic stenosis. The examiner palpates simultaneously the right brochial artery of the patient with the thumb and the right radial artery of the patient with the middle or index finger. Any palpable delay between the brachial artery and radial artery is considered abnormal. 6 Sudden death, usually from an dysrhythmia, occurs in 25 percent of patients. The ECG usually demonstrates criteria for LVH and, in 10 percent of patients, left or right bundle branch block. The chest radiograph is normal early, but eventually LVH and findings of congestive heart failure are evident if the patient does not have valve replacement.

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