Screening for aortic stenosis using physical examination and echocardiography

Most patients with aortic stenosis (AS) can be treated with either traditional surgical aortic valve replacement or newly emerged transcatheter aortic valve implantation. Therefore, the early and appropriate detection of significant AS has become more important for avoiding overlooking patients who require treatment. AS is initially detected by the presence of a systolic ejection murmur (SEM). However, it is time-consuming and expensive for all subjects presenting with SEM to undergo comprehensive standard echocardiography using high-end ultrasound machines since the SEM is audible in a large proportion of elderly patients and is not specific for significant AS. Therefore, further physical examination and/or focused cardiac ultrasound (FoCUS) is required to determine whether patients with a SEM should be referred for standard echocardiography. One or more abnormal physical findings in addition to a SEM can rule out a certain proportion of normal cases without overlooking severe AS. Most of the previous studies suggesting the usefulness of FoCUS in screening for valvular heart disease only used visual impressions in their assessment of AS. By contrast, visual AS and calcification scores are good objective parameters in screening for AS with FoCUS. Patients with severe AS and patients with a high probability of AS-related events are rarely overlooked even if comprehensive standard echocardiography is performed only when either (or both) of the FoCUS scores is 3 or more. The appropriate combination of physical examinations and FoCUS to screen for AS is discussed in this review article.