Identifying Severe Aortic Valvular Stenosis by Bedside Examination

Publisher Website
Google Scholar
Abstract
Sixty-seven consecutive symptomatic patients with aortic valvular stenosis (AS) and no or slight aortic incompetence were prospectively examined bedside by a senior cardiologist before an invasive pre-operative investigation. A history of effort syncope had the highest predictive value (pos), 100%, for a significant degree of AS (defined as a calculated valve area .ltoreq. 0.9 cm2 or a peak systolic pressure difference across the valve of .gtoreq. 40 mmHg). The absence of effort syncope had a predictive value (neg) of 40%. The corresponding figures for peak intensity of the murmur in mid-systole were 93 adn 82%, respectively. For the combination of effort syncope and/or mid-systolic peak intensity of the murmur (borderline findings included) the predictive values were 90% (pos) and 94% (neg), respectively. No other combination of symptoms and physical finding was more discriminating. This combination of criteria for prediction of a significant stenosis was prospectively applied to the next 39 AS patients. The criteria were fulfilled by 29 patients and all were found to have a significant AS as were four of the 10 patients not fulfilling the criteria. These four falsely negative patients had a valve area/peak pressure difference of 0.5, 0.8, 0.8 cm2 and 43 mmHg. The inter-observer variation was studied in a third series by two senior cardiologists independently examining 22 AS patients. They were concordant in all with regard to a history of effort syncope and in all but one (0.6 cm2) with regard to the timing of the peak murmur. Bedside examination of an AS patient by an experienced cardiologist has a good predictivity for severity, and the inter-observer variation is low. Non-invasive laboratory investigations have only a supplementary role. However, as many patients have effort angina, a pre-operative invasive procedure including coronary arteriography is often unavoidable.