1. Always mention presence/absence of signs of endocarditis in any patient with physical signs of valvular heart disease. More than often, they are absent—but this is an important negative finding. 2. Both a low volume and a slow-rising pulse are signs of severe aortic stenosis. If the patient is in atrial fibrillation (AF), then the pulse usually has a variable volume, and some examiners believe that one cannot fully conclusively comment on pulse volume in AF. In patients with aortic stenosis and AF, the pulse exhbits a variable but diminished volume. It would be more appropriate in this setting to say, ‘the pulse is of variable but diminished volume’. 3. A narrow pulse pressure signifies a low cardiac output state, thus a sign of severe aortic stenosis. Other causes of a narrow pulse pressure include severe mitral stenosis or a hypovolaemic state. 4. If venous pressure is elevated, then look for signs of pulmonary hypertension (usually with giant systolic ‘v’ waves of tricuspid regurgitation, parasternal heave and thrill, and a loud pulmonary component to the second heart sound) or pulmonary congestion/cardiac failure (bibasal crepitations). The presence of pulmonary hypertension and pulmonary congestion are markers of severe aortic stenosis. 5. The left ventricle (LV) is hypertrophied, and is minimally displaced with a heaving character. A displaced apex beat indicates a dilated left ventricle, i.e. left ventricular failure. In the late stages of severe aortic stenosis, the left ventricle dilates and heart failure develops. However, the character of the apex beat remains the same. If the apex is displaced, in the absence of signs of severe aortic stenosis, then consider other causes of heart failure. 6. The presystolic impulse is transmission of atrial contraction just before closure of the mitral valve, as a result of forceful atrial contraction against a highly non-compliant and hypertrophied left ventricle. This is often accompanied by a fourth heart sound, and would be a marker of severe aortic stenosis. These signs would not be present in AF. A presystolic impulse is seen in other conditions with marked left ventricular hypertrophy, i.e. hypertensive heart disease or hypertrophic cardiomyopathy (giving a double apical impulse).
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