Q J Med 2001; 94: 49
© 2001 Association of Physicians
Correspondence |
Systolic murmur and aortic stenosis
Department of Medicine for the Elderly, Tameside General Hospital, Ashton under Lyne
Sir,
The recognition and correct interpretation of systolic murmurs is indeed fundamental to the early diagnosis of aortic stenosis,1 even when the initial perception is that the murmur originates from the mitral valve, since mitral regurgitation may itself be a defining characteristic of severe aortic stenosis,2 the aortic murmur sometimes even decreasing in intensity with the progress of the disease.3 The confusion between mitral vs. aortic origin of the systolic murmur is compounded by the coexistence of atrial fibrillation (AF). AF has recently been shown to be significantly associated with the risk of clinically missing the diagnosis of severe AS, the aortic murmur being mistaken for a mitral murmur, in the presence of AF,4 notwithstanding the fact that, in patients aged >75, with aortic stenosis, AF may be a feature in as many as 14%.5 These observations lend support to the view that ‘the ability of cardiac examination to assess the exact cause of the murmur is limited, especially if more than one lesion is present’.6 Equally important is the observation that either systolic or diastolic hypertension (characterized by blood pressures of >160 mmHg and >95 mmHg, respectively) may coexist with critical symptomatic aortic stenosis in as many as 8% and 24% of cases, respectively,7 notwithstanding the older teaching that, in AS, ‘the blood pressure is usually normal or the systolic pressure is low and the pulse pressure reduced’,8 one qualification being the caveat invoked by the late Paul Wood, that ‘it is extremely rare for a case of severe organic aortic stenosis to have a systolic blood pressure of 200 mmHg or more under any circumstances’.9
References
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Das P, Pocock C, Chambers J. The patient with a systolic murmur: severe aortic stenosis may be missed during cardiovascular examination. Q J Med2000; 93:685–8.
2.
Otto CM, Burwash IG, Legget ME. Prospective study of asymptomatic valvular aortic stenosis. Clinical, echocardiographic and exercise predictors of outcome. Circulation1997; 95:2262–70.
3. Morgan DJR, Hall RJC. Occult aortic stenosis as a cause of intractable heart failure. Br Med J1979; 1:784–7.
4. Rispler S, Rinkevich D, Markiewicz, Reisner SA. Missed diagnosis of severe symptomatic aortic stenosis. Am J Cardiol1995; 76:728–30.[Web of Science][Medline]
5. Iivanainen AM, Lindroos M, Tilvis R, Heikkila J, Kupari M. Natural history of aortic valve stenosis of varying severity in the elderly. Am J Cardiol1996; 78:97–101.[Web of Science][Medline]
6. Attenhofer CH, Turina J, Mayer K, et al. Echocardiography in the evaluation of systolic murmurs of unknown cause. Am J Med2000; 108:614–20.[Web of Science][Medline]
7.
Zezulka A, Mackinnon J, Beevers DG. Hypertension in aortic valve disease and its response to valve replacement. Postgrad Med J1992; 68:180–5.
8. Schrire V. Aortic stenosis. In Schrire V, ed. Clinical Cardiology, 3rd edn. London, Staples Press, 1971: 395–8.
9. Wood P. Aortic Stenosis. Am J Cardiol1958; 1:553–71.[Web of Science][Medline]
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