The apical impulse is thrusting in quality as a result of ventricular hypertrophy. A systolic thrill maximal in the same areas as the murmur and likewise transmitted into the neck is a common, but not invariable accompaniment. An aortic diastolic murmur is often present but without peripheral signs of free aortic incompetence, i.e. undue arterial pulsations. Lowered systolic blood pressure and decreased pulse pressure. Left ventricular enlargement or hypertrophy may be confirmed by radiography and electrocardiography. Calcification of aortic valves may be seen on the radiological screen. The severity of aortic stenosis must be judged by judged by symptoms and the degree of left ventricular hypertrophy. Auscultator findings and blood pressure readings may be misleading.
Owing to the ability of the powerful left ventricle to deal with the reflux of blood which occurs in diastole compensation may be excellent for many years. In time left ventricular failure occurs and progressive dyspnoea on exertion is soon followed by paroxysmal dyspnoea at rest, orthopnoea and finally congestive cardiac failure. The characteristic and most important sign of aortic incompetence is a high-pitched blowing early diastolic murmur commencing immediately after the second heart sound and best heard down the left sterna edge with the patient standing or sitting and the left sterna edge with the patient standing or sitting and the breath held in expiration. A blowing systolic murmur is a common accompaniment. Collapsing or water –hammer radial pulse. There is an abrupt upstroke with sudden impact against the examining finger and a rapid falling away or collapse. Associated peripheral vasodilatation gives rise to pink and warm extremities and to capillary pulsation, e.g. in the nail beds. Radiography will show the degree of left ventricular enlargement and the electrocardiogram may show the pattern of left ventricular hypertrophy.
Peripheral cyanosis and a small volume pulse may be present and are due to vasoconstriction. The apical impulse is often ‘tapping’ in quality, and a right ventricular thrust may be felt behind and to the left of the lower sternum and in the epigastria. A diastolic thrill is often palpable at the apex. A diastolic murmur maximal at or confined to the region of the apex beat is the hallmark of mitral stenosis. The murmur may be pre-systolic in time or fill most of diastole with apparent pre-systolic accentuation. It is usually low-pitched and rumbling in quality and best heard with a bell stethoscope and the patient lying on the left side. In early cases it may only be heart if the heart rate is increased, e.g. by exercise. The pre-systolic part of the murmur is dependent on trail systole, and hence disappears with the onset of atrial fibrillation. The first heart sound at the apex is characteristically loud and sudden. An added sound may be accentuated from pulmonary hypertension. An added sound may frequently be heard immediately preceding the mid-diastolic murmur. Enlargement of the left the opening of the readily be seen on radiological examination, especially in the right oblique position, in barium – filled oesophagus Calcification of the mitral valve may be observed. Later enlargement of the pulmonary artery and of the right ventricle occurs.
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