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Reliable, easy-to-read patient information on common medical conditions — written in plain language, free of jargon, and grounded in current evidence. Browse the most frequent diagnoses, understand what they mean for everyday life, and learn which steps and questions help you have a focused conversation with your doctor.

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Aortic stenosis differential diagnosis

Introduction

Overview

Overview

Aortic stenosis must be differentiated from other cardiac or pulmonary causes of dyspnea, weakness, and dizziness. Furthermore, when left ventricular outflow tract obstruction is present, it is critical to identify whether the obstruction is subvalvular, valvular or supravalvular and whether there is hypertrophic cardiomyopathy (HOCM) or not.[1]

Differentiating Aortic Stenosis from other Diseases

Differentiating Aortic Stenosis from other Diseases

Aortic stenosis must be differentiated from the following:[2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24]

Diseases History Symptoms Physical Examination Murmur Diagnosis Other Findings
ECG CXR Echocardiogram Cardiac Catheterization
Aortic stenosis
  • Age (aortic valve calcification)
  • Syncope
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Acute rheumatic fever
  • Chest pain
  • Dyspnea on exertion
  • Palpitations
  • Symptoms of heart failure
  • Pulsus parvus et tardus
  • Pulmonary rales
  • Peripheral edema (In CHF patients)
  • Jugular venous distension
  • Enlarged and laterally displaced point of maximal impulse
    • Crescendo-decrescendo systolic murmur
    • Best heard at the right upper sternal border
    • Radiation to the carotid arteries
    • Increases with squatting
    • Decreases with valsalva maneuver
    		 Left ventricular hypertrophy:
    • Wide QRS complex (especially in leads V1-V6)
    • ST depression in leads V5-V6
    • Left axis deviation
    • Enlarged left ventricle
    • Enlarged left atrium and pulmonary artery in severe cases
    • Calcification of the aortic valve
    • Thickening and calcification of the aortic valve
    • Left ventricular hypertrophy
    		 Left heart catheterization:
    • Left ventricular and aortic pressures
    • The left ventricle generates higher pressures than what is transmitted to the aorta
    • Associated with von Willibrand disease
    Mitral Stenosis
    • Age ( Mitral annular calcification in older patients)
    • Mitral facies
    • Heart murmur
    • Apical impulse displaced laterally or not palpable
    • Diastolic thrill at the apex
    • Signs of heart failure in severe cases
    • Diastolic murmur
    • Low pitched
    • Opening snap followed by decrescendo-crescendo rumbling murmur
    • Best heard with the bell of the stethoscope at apex at end-expiration in left lateral decubitus position
    • Intensity increases after a valsalva maneuver, after exercise and after increased after load (eg., squatting, isometric hand grip)
    • Right ventricular hypertropy: Dominant R wave in V1 and V2
    • Straightening of the left border of the heart suggestive of enlargement of the left atrium
    • Double right heart border (Enlarged left atrium and normal right atrium)
    • Prominent left atrial appendage
    • Reduced valve leaflet mobility
    • Valve calcification
    • Doming of mitral valve
    • Valve thickening
    • Enlargement of left atrium
    		 Right heart catheterization:

    Left heart catheterization:

    • Pressures in left ventricle
    • Determines the gradient between the left and right atrium during ventricular diastole (marker of the severity of mitral stenosis)
    Mitral Regurgitation
    • Trauma
    • Symptoms of heart failure in severe cases
    		 Palpation
    • Brisk carotid upstroke and hyperdymanic carotid impulse on palpation
    • Apical impulse is displaced to left
    • S3 and a palpable thrill

    Auscultation

    • Murmur
    • High pitched, blowing
    • Radiates to axilla
    • Best heard with the diaphragm of the stethoscope at apex in left lateral decubitus position
    • Intensity increases with hand grip or squatting
    		 Acute MR

    Chronic MR

    • Enlarged cardiac silhouette
    • Straightening of left heart border
    • Splaying of subcarinal angle
    • Calcification of mitral annulus
    • Double right heart border
    • Enlargement of left atrium and ventricle
    • Identify valve abnormality
    • Valve calcification
    • Severity of regurgitation
    • Grading of MR is done with left ventriculography
    Atrial septal defect
    • Frequent respiratory or lung infections
    • Dyspnea
    • Tiring when feeding (Infants)
    • Shortness of breath on exertion
    • Palpitations
    • Swelling of feet
    		 Inspection
    • Precordial bulge
    • Precordial lift

    Palpation

    • Right ventricular impulse
    • Pulmonary artery pulsations
    • Thrill

    Auscultation

    • Murmur
    • Midsystolic (ejection systolic) murmur
    • Widely split, fixed S2
    • Upper left sternal border
    • Increased pulmonary markings
    • Cardiomegaly
    • Triangular appearance of heart
    • Schimitar sign
    Left Atrial Myxoma
    • Symptoms may mimic mitral stenosis
    		 Skin

    Auscultation:

    • Lung: Fine crepitations
    • Heart: Characteristic “tumor plop”
    • Early diastolic sound as “tumor plop”
    • Low frequency diastolic murmur may be heard if the tumor obstructing mitral valve
    • Often normal
    • Often normal

    Rare findings:

    • cardiomegaly
    • Left atrial enlargement
    • tumor calcification etc.,
    • Useful to detect vascular supply of the tumor by the coronary arteries
    • Associated with Carney complex (genetic predisposition)
    Prosthetic Valve Obstruction
    • History of valve replacement
    • Systemic embolism
    • Shortness of breath
    • Fatigue
    		 Ausculation

    Muffling of murmur

    • Muffling or disappearance of prosthetic sounds
    • Appearance of new regurgitant or obstructive murmur
    		 − −
    • Degree of stenosis
    • Assess thrombus size and location
    • Differentiate between thrombus, pannus and vegetations
    		 Causes:
    • Thrombus
    • Pannus formation
    Cor Triatriatum
    • Dsypnea on exertion
    • Orthopnea
    • Tachypnea
    • Palpitations
    • Growth failure
    		 Auscultation
    • Murmur

    Other findings

    • Signs of heart failure
    • Diastolic murmur with loud P2
    • No opening snap or a loud S1
    		 Non specific but may have
    • Normal cardiac silhouette
    • Hemodynamic changes similar to mitral stenosis (non specific findings)
    • Direct visualization of membrane through the atrium
    • +/- visualization of accessory chamber
    • Normal left ventricular hemodynamic profile with a trans atrial gradient
    		 Types
    • Cor triatriatum sinistrum
    • Cor triatriatum dextrum
    Congenital Mitral Stenosis
    • Respiratory distress shortly after birth
    • Recurrent severe pulmonary infections
    • Other associated congenital cardiovascular anamolies
    • Atrial fibrillation

    Infants:

    • Exhaustion and sweating on feeding
    • Rapid breathing
    • Failure to thrive
    • Pulmonary infections
    • Chronic cough

    Older patients:

    • Dyspnea
    • Orthopnea
    • Paroxysmal nocturnal dyspnea
    • Peripheral edema
    • Fatigue
    		 Auscultation
    • Murmur

    Other findings

    • Signs of heart failure
    		 Mild-Moderate
    • Loud S1
    • Loud P2
    • Low frequency diastolic murmur best heard at the apex

    Severe

    • Soft S1
    • Loud pulmonic component of S2 with minimal respiratory splitting of S2
    • Holodiastolic murmur with presystolic accentuation best heard at the apex
    • Early diastolic murmur of pulmonic valve regurgitation
    • Sharp P waves in leads I and II
    • Inversion of P wave in lead III
    • Marked Q waves in leads II and III
    • Left atrial dilation
    • Moderate enlargement of right heart
    • Pulmonary venous congestion
    • Esophageal compression
    • Reduced valve leaflet mobility
    • Left atrial size
    • Severity of mitral stenosis
    		 Very rare condition
    Supravalvular Ring Mitral Stenosis
    • Other associated congenital heart defects
    • Fatigue
    • Frequent respiratory infections
    • Failure to thrive
    • Poor feeding
    • Precocious congestive heart failure
    • Shortness of breath
    • Tachypnea
    • Dyspnea
    • Nocturnal cough
    • Heamoptysis
    • Syncope
    		 Auscultation:

    Lungs: Fine, crepitant rales and rhonchi or wheezes may be present

    Heart: Murmur

    • An apical mid diastolic murmur with presystolic accentuation
    • No opening snap
    • The murmur is more prominent if associated with VSD or PDA
    • Left atrial and ventricular enlargement
    • Alveolar edema
    		 Supramitral ring:
    • Associated with normal mitral valve apparatus

    Intramitral ring:

    • Hypomobility of the posterior leaflet
    • Reduced interpapillary muscle distance
    • Reduced chordal length
    • Dominant papillary muscle
    • Hypoplastic mitral annulus

    (Difficult to visualize membrane <1mm in size)

    • Persistently elevated pulmonary venous pressures
    • Increased pulmonary artery pressure
    		 Types
    • Supramitral
    • Intramitral

    It is attached between the opening of the atrial appendage and the mitral annulus which helps in differentiating with Cor triatriatum sinister.

    • Intramitral type is associated with shone complex
    References

    References

    1. ↑ Cleland JG, Swedberg K, Follath F, Komajda M, Cohen-Solal A, Aguilar JC, Dietz R, Gavazzi A, Hobbs R, Korewicki J, Madeira HC, Moiseyev VS, Preda I, van Gilst WH, Widimsky J, Freemantle N, Eastaugh J, Mason J (2003). “The EuroHeart Failure survey programme– a survey on the quality of care among patients with heart failure in Europe. Part 1: patient characteristics and diagnosis”. European Heart Journal. 24 (5): 442–63. PMID 12633546. Retrieved 2012-04-11. Unknown parameter |month= ignored (help)
    2. ↑ Nassar PN, Hamdan RH (2011). “Cor Triatriatum Sinistrum: Classification and Imaging Modalities”. Eur J Cardiovasc Med. 1 (3): 84–87. doi:10.5083/ejcm.20424884.21. PMC 3286827. PMID 22379596.
    3. ↑ Roudaut R, Serri K, Lafitte S (2007). “Thrombosis of prosthetic heart valves: diagnosis and therapeutic considerations”. Heart. 93 (1): 137–42. doi:10.1136/hrt.2005.071183. PMC 1861363. PMID 17170355.
    4. ↑ Apostolakis EE, Baikoussis NG (2009). “Methods of estimation of mitral valve regurgitation for the cardiac surgeon”. J Cardiothorac Surg. 4: 34. doi:10.1186/1749-8090-4-34. PMC 2723095. PMID 19604402.
    5. ↑ Alboliras ET, Edwards WD, Driscoll DJ, Seward JB (1987). “Cor triatriatum dexter: two-dimensional echocardiographic diagnosis”. J Am Coll Cardiol. 9 (2): 334–7. PMID 3805524.
    6. ↑ Gibson DG, Honey M, Lennox SC (1974). “Cor triatriatum. Diagnosis by echocardiography”. Br Heart J. 36 (8): 835–8. PMC 458901. PMID 4412638.
    7. ↑ Cor triatrium https://radiopaedia.org/articles/cor-triatriatum (2016) Accessed on November 29, 2016
    8. ↑ Sosland RP, Vacek JL, Gorton ME (2007). “Congenital mitral stenosis: a rare presentation and novel approach to management”. J Thorac Cardiovasc Surg. 133 (2): 572–3. doi:10.1016/j.jtcvs.2006.10.025. PMID 17258606.
    9. ↑ Driscoll DJ, Gutgesell HP, McNamara DG (1978). “Echocardiographic features of congenital mitral stenosis”. Am J Cardiol. 42 (2): 259–66. PMID 685838.
    10. ↑ Bonou M, Lampropoulos K, Barbetseas J (2012). “Prosthetic heart valve obstruction: thrombolysis or surgical treatment?”. Eur Heart J Acute Cardiovasc Care. 1 (2): 122–7. doi:10.1177/2048872612451169. PMC 3760527. PMID 24062899.
    11. ↑ Maganti K, Rigolin VH, Sarano ME, Bonow RO (2010). “Valvular heart disease: diagnosis and management”. Mayo Clin Proc. 85 (5): 483–500. doi:10.4065/mcp.2009.0706. PMC 2861980. PMID 20435842.
    12. ↑ DEXTER L (1956). “Atrial septal defect”. Br Heart J. 18 (2): 209–25. PMC 479579. PMID 13315850.
    13. ↑ Webb G, Gatzoulis MA (2006). “Atrial septal defects in the adult: recent progress and overview”. Circulation. 114 (15): 1645–53. doi:10.1161/CIRCULATIONAHA.105.592055. PMID 17030704.
    14. ↑ Geva T, Martins JD, Wald RM (2014). “Atrial septal defects”. Lancet. 383 (9932): 1921–32. doi:10.1016/S0140-6736(13)62145-5. PMID 24725467.
    15. ↑ Demir M, Akpinar O, Acarturk E (2005). “Atrial myxoma: an unusual cause of myocardial infarction”. Tex Heart Inst J. 32 (3): 445–7. PMC 1336732. PMID 16392241.
    16. ↑ MacGowan SW, Sidhu P, Aherne T, Luke D, Wood AE, Neligan MC; et al. (1993). “Atrial myxoma: national incidence, diagnosis and surgical management”. Ir J Med Sci. 162 (6): 223–6. PMID 8407260.
    17. ↑ Circulation http://circ.ahajournals.org/content/119/7/1034 (2016) Accessed on December 7, 2016
    18. ↑ Alphonso N, Nørgaard MA, Newcomb A, d’Udekem Y, Brizard CP, Cochrane A (2005). “Cor triatriatum: presentation, diagnosis and long-term surgical results”. Ann Thorac Surg. 80 (5): 1666–71. doi:10.1016/j.athoracsur.2005.04.055. PMID 16242436.
    19. ↑ circulation http://circ.ahajournals.org/content/36/1/101 (1967) Accessed on 7 December, 2016
    20. ↑ Moore P, Adatia I, Spevak PJ, Keane JF, Perry SB, Castaneda AR; et al. (1994). “Severe congenital mitral stenosis in infants”. Circulation. 89 (5): 2099–106. PMID 8181134.
    21. ↑ Uva MS, Galletti L, Gayet FL, Piot D, Serraf A, Bruniaux J; et al. (1995). “Surgery for congenital mitral valve disease in the first year of life”. J Thorac Cardiovasc Surg. 109 (1): 164–74, discussion 174-6. doi:10.1016/S0022-5223(95)70432-9. PMID 7815793.
    22. ↑ Banerjee A, Kohl T, Silverman NH (1995). “Echocardiographic evaluation of congenital mitral valve anomalies in children”. Am J Cardiol. 76 (17): 1284–91. PMID 7503011.
    23. ↑ Sullivan ID, Robinson PJ, de Leval M, Graham TP (1986). “Membranous supravalvular mitral stenosis: a treatable form of congenital heart disease”. J Am Coll Cardiol. 8 (1): 159–64. PMID 3711511.
    24. ↑ Subramaniam V, Herle A, Mohammed N, Thahir M (2011). “Ortner’s syndrome: case series and literature review”. Braz J Otorhinolaryngol. 77 (5): 559–62. PMID 22030961.

    Cardiology

    Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Mohammed A. Sbeih, M.D. [2]; Usama Talib, BSc, MD [3] Kristin Feeney, B.S. [4]