**4.4 Calcific AS in the elderly**

Patients with milder forms of calcific AS are asymptomatic and are usually detected because of a cardiac murmur heard on routine physical examination or by an echocardiographic study performed for an unrelated reason. Moderate to severe forms may present with symptoms of dyspnea on exertion or exercise intolerance. Rarely, the presenting symptoms such as syncope, chest pain, or signs of CHF may appear. Physical examination reveals increased left ventricular impulse; slow upstroke of the pulse (pulsus tardus) and small pulse volume (pulsus parvus), both are better perceived in carotid than in radial and brachial pulses; ejection systolic click at the apex, unless the aortic valve is immobile because of marked calcification; soft aortic component of the second heart sound; and an ejection systolic murmur, heard at the right upper sternal border, radiating to the carotid arteries. Higher grades of the murmur (grade IV) and late peaking in systole suggest more severe obstruction.

#### **4.5 Aortic insufficiency**

Most patients with mild to moderate AI are asymptomatic and are detected because of a cardiac murmur. Severe AI patients present with symptoms of easy fatigability, dyspnea on exertion, or chest pain. On physical examination, while the peripheral pulses are normal in mild AI, they are increased and "bounding" in patients with moderate and severe AI. The pulse pressure is increased secondary to increased systolic blood pressure with a concurrent decrease in diastolic pressure. Peripheral signs of AI such as water-hammer pulse (rapid increase and decrease of pulse when palpating the forearm), Corrigan's pulse (strikingly augmented carotid pulses), Duroziez's murmur [bruits both in systole and diastole auscultated in the femoral artery region while it is partially occluded], pistol shot sounds (systolic and diastolic vibrations of the arterial wall—Traube's sign), and Quinke's pulse (flushing and blanching alternatively of the capillary beds of the tips of finger) are seen in subjects with moderate to severe AI; however, these signs do not inevitably categorize that the AI is severe. The left ventricular impulse is prominent to hyperdynamic. The diastolic thrill of AI is rarely felt. In general, there are no abnormal cardiac sounds. If the AI is due to a bicuspid aortic valve, an aortic systolic click is auscultated. A systolic ejection murmur is heard at the upper right or at mid-left sternal borders; this may be related to the increased volume of blood that has to be pumped back via the aortic valve. Alternatively, the systolic component may be due to associated aortic valve stenosis. An early diastolic decrescendo murmur is auscultated at the right upper and left mid sternal borders. The murmur has a high pitch and is heard better with the diaphragm than the bell of the stethoscope. The murmur begins with the aortic component of the 2nd sound and is better heard when the patient sits up, leans forward, and holds the breath at end-expiration. It may transmit inferiorly to the left lower sternal border. An Austin-Flint type of mid-diastolic murmur may be appreciated at the apex.
