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Aortic stenosis: diagnosis and management

BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5425 (Published 19 October 2016) Cite this as: BMJ 2016;355:i5425

Rapid Response:

Re: Aortic stenosis: diagnosis and management distinguishing between aortic stenosis and mitral regurgitation

Given the fact that, in developed countries, aortic stenosis is the most prevalent of all valvular diseases(1), the authors of the review article (2) should have done more to draw attention to the potential for missed diagnosis when this common disorder (in which surgical intervention may be life changing) is mistaken for mitral regurgitation, where indications for surgical intervention may, arguably, not be so clearcut. The systolic murmur of aortic stenosis may be mistaken for the systolic murmur of mitral regurgitation, either when the murmur of aortic stenosis (AS) is conducted to the cardiac apex (3), or when atrial fibrillation (AF) coexists (4), given the fact that mitral regurgitation is one of the valvular disorders commonly associated with AF (5). In the presence of sinus rhythm dynamic auscultation is the strategy which helps to distinguish the systolic murmur of aortic stenosis from the systolic murmur of mitral regurgitation (6). The murmur of AS is augmented by squatting, due to the fact that squatting increases stroke volume and, hence, transvalvular blood flow. Conversely, the intensity of the murmur is reduced on standing, due to a corresponding reduction in transvalvular blood flow (6). These procedures do not affect the murmur of mitral regurgitation.

In the presence of atrial fibrillation the intensity of the aortic systolic murmur varies from beat to beat, due to variation in diastolic filling (6). This variation in diastolic filling does not affect the intensity of the systolic murmur of mitral regurgitation (6).

References
(1) Carabello BA., Paulus WJ. Aortic stenosis. Lancet 2009;373;956-966
(2) Zakkar M., Bryan AJ., Angelini GD. Aortic stenosis: diagnosis and management. BMJ 2016;355:i5425
(3) Braunwald E. Valvular Heart Disease. in Harrison's Principles of Internal Medicine 14th Edition 1998. Chapter 237.Editors Fauci AS., Braunwald E., IsselbacherKJ., Wilson JD., Martin JB., Kasper DL., Hauser SL., Longo DL. McGraw-Hill Health Professions Division. New York., St Louis., San Fransisco
(4) Rispler S., Rinkevich D., Markiewicz., Reisner SA. Missed diagnosis of svere symptomatic aortic stenosis. Am J Cardiol 1995;76:728-730
(5) Braunwald E. Valvular Heart Disease. in Harrison's Principles of Internal Medicine 14th Edition 1998. Chapter 237. Editors Fauci AS., Braunwald E., Isselbacher K., Wilson JD., Martin JB., Kasper DL., Hauser DL., Longo DL. McGraw-Hill Health Professions Division. New York, St Louis., San Fransisco
(6) Otto CW., Bonow RO. Valvular Heeart Disease. in Braunwald's Heart Disease: A textbook of Cardiovascular Medicine 2014 Tenth edition p 1446-1523. Editors Mann DL., Zipes DP., Libby P., Bonow RV.
Elsevier Saunders Philapelphia

Competing interests: No competing interests

26 October 2016
Oscar M Jolobe
retired geriatrician
manchester medical society
Manchester M20 6BR