Aortic stenosis causes delayed closure of the aortic valve leading to reversed splitting of the 2nd heart sound. The 2nd heart sound is split, especially during expiration, due to the pulmonary valve closing prior to the aortic. In inspiration, there is virtually no split (or minor) in the 2nd heart sound due to the pulmonary valve being delayed in closure.

The patient presented here has both aortic valve incompetence, with aortic stenosis, and hence both systolic and diastolic murmurs can be heard. You cannot hear any of the 2nd heart sound.

Other associated clinical features:

  • regular pulse
  • slowing rising pulse (AS)
  • collapsing pulse (AR)
  • normal JVP
  • palpable apex beat, displaced laterally of the mid-clavicular line
  • forceful heave that is sustained (AS)
  • thrusting apex beat in mid-axillary line (AR)
  • palpable systolic thrill at the displaced apex, aortic and carotid areas
  • low pulse pressure (AS)
  • wide pulse pressure (AR)