Possible DDx for AS

1. Mitral regurgitation

- This is a condition where mitral valve allows part of left ventricular stroke volume to regurgitate into the left atrium, imposing load on both ventricle and atrium. Usually, holosystolic, soft murmur is heard when auscultated at the apex together with radiation to the left axilla, medium to high pitch with a blowing quality. In posterior cusps disorder of mitral valve results murmur that is radiating towards sterna border rather than the apex, increased intensity through the duration of systole and peaks late during systole.

2. Hypertrophic obstructive cardiomyopathy

-Also known as idiopathic hyperthropic subaortic stenosis (IHSS) where there is thickening of the myocardium which reduce blood flow from the heart thus decreasing cardiac output. The standing and the strain phase of Valsalva can increase the intensity of HOCM murmur and mimic a murmur consistent with AS. IHSS is ruled out from AS by the diminished systolic murmur with squatting and the biphasic pulse.

3. Supravalvular aortic stenosis

-A condition where the ascending aorta beyond the superior margin of the sinuses of Valsalva is narrowed and leads to LV hypertrophy. Patients may show up with dyspnea on exertion, angina and syncope. Upon auscultation, murmur is crescendo-decrescendo in shape, low pitched and best heard at the base of the heart where the site is higher in valvular aortic stenosis. The findings that rule out Suprevalvular aortic stenosis is the absence of ejection click and cineangiography.

4. Congenital subvalvular aortic stenosis

-The physical findings in this condition shows major resemblance to those with AS except the initiation of aortic valve closure from the increased level of aortic pressure proximal to stenotic area, sporadic systolic ejection sound, transmission of a thrill and murmur to the neck. In physical examination, patients reveals higher systolic pressure in right arm than the left because of the selective streaming of blood into the innominate artery.

5. Ventricular Septal Defect (VSD)

-This condition can be either congenital or acquired following episodes of MI. VSD murmur can present depending on how severe the defect is and also the pressure difference between right and left ventricles. Holosystolic or crescendo-decrescendo murmur maybe heard during auscultation in VSD which mimics AS murmur. Echocardiography is widely used to differentiate VSD from AS.

6.Aortic sclerosis
-Results from degeneration and calcification of the aortic cusps, predominantly at their base. This abnormality produces a peaked midsystolic murmur, accompanied by a normal second heart sound and carotid pulse upstroke that is identical in character to aortic valvular stenosis. The responses to physiologic and pharmacologic interventions are identical to those of functional systolic ejection murmurs. Echocardiographic studies suggest that aortic sclerosis is common in the elderly and may be the single most common cause of systolic murmur in this population.


Causes of systolic heart murmur
-valvular aortic stenosis
-aortic sclerosis
-supravalvular aortic stenosis
-subvalvular aortic stenosis
-hypertrophic obstructive cardiomyopathy
-valvular pulmonic stenosis
-pulmonary infundibular stenosis
-atrial septal defect
-tetralogy of Fallot

Causes of chest pain
Angina
MI
Pleuritic pain
Cervical or upper thoracic spine disease
Dissecting aneurysm
Massive pulmonary embolism
Spontaneous pneumothorax
Gastro-oesophageal reflux
Cholescystitis
Virus (eg, Coxsackie B infection, HZV)


Reference List
-Tally and O'Connor. Clinical Examination: a systematic guide to physical diagnosis.
-http://www.fpnotebook.com/cv/valve/artcstns.htm
-www.acponline.org/essentials.
-K. Parven & C. Michael (eds.) 2009, Kumar & Clark's Clinical Medicine Seventh Edition
-Lim, E Loke, YK & Thompson, A 2007. Medicine and Surgery an Integrated Textbook, Elsevier Limited.
-http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=A746