MioAtlas
Comparison

Calcific aortic stenosis vs Chronic aortic regurgitation: clinical and ECG differences

Side-by-side comparison of Calcific aortic stenosis and Chronic aortic regurgitation according to the MioAtlas 3D cardiac simulator model.

Calcific aortic stenosis
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Chronic aortic regurgitation
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Findings by layer and diagnostic parameters

Layer / Finding Calcific aortic stenosis Chronic aortic regurgitation
Hemodynamics
  • Aortic mean gradient: L < 20 mmHg, M 20–39 mmHg, G ≥ 40 mmHg [V1] [V4].
  • Peak aortic velocity: L 2.6–2.9 m/s, M 3.0–3.9 m/s, G ≥ 4.0 m/s [V1] [V4].
  • Systemic arterial pressure: In severe stages, narrow pulse pressure with delayed systolic rise [B4] [V1].
  • Regurgitant volume (RV) and regurgitant fraction (RF): Transaortic valvular quantification (RV < 30 mL, RF < 30% in mild; RV 30–59 mL, RF 30–49% in moderate; RV ≥ 60 mL, RF ≥ 50% in severe) [V1] [V3].
  • Blood pressure: Markedly wide pulse pressure in severe forms (systolic hypertension with very low diastolic, e.g., 123/23 mmHg) [V1] [V3].
  • Ventricular volumes: Progressive left ventricular dilation with marked increase in end-diastolic volume and elevated total cardiac output with preserved or decreased effective forward stroke volume in late stages [V1] [V3].
Rhythm
  • Normal sinus rhythm [V1].
  • In advanced stages or calcification extending to the AV node: possible atrial fibrillation or conduction disturbances [E2] [V1].
  • Normal sinus rhythm [V1].
ECG
  • Concentric left ventricular hypertrophy due to systolic pressure overload (left ventricular hypertrophy voltage criteria, positive Sokolow-Lyon / Cornell criteria with ST depression and asymmetric T-wave inversion in lateral leads) [E1] [V1].
  • Left ventricular hypertrophy due to volume overload (left ventricular hypertrophy voltage criteria, tall R waves with tall peaked positive T waves in precordial leads V5 and V6 in early stages, or systolic overload pattern with ST depression and T wave inversion in advanced stages) [E1] [V1].
Heart sounds and murmurs
  • Systolic murmur: Rough, harsh ejection mesosystolic murmur (crescendo-decrescendo) at the 2nd right intercostal space (aortic area), classically radiating to the carotid arteries [G1-14] [V4].
  • Gallavardin phenomenon: Acoustic dissociation in the elderly where the high-frequency component of the murmur is auscultated as musical and pure at the cardiac apex, mimicking mitral regurgitation [G1-14].
  • Second heart sound (S2): Aortic component (A2) decreased, soft, or absent in severe forms due to extreme calcific cusp rigidity; possible paradoxical splitting of S2 [G1-11] [V4].
  • Fourth heart sound (S4): Frequent in sinus rhythm due to atrial contraction against a non-compliant hypertrophied ventricle [G1-13].
  • Diastolic murmur: High-pitched, early diastolic decrescendo blowing murmur, auscultated with diaphragm at the 3rd left intercostal space / aortic area (site: aortic, pitch: high, shape: decrescendo) [V1] [V3] [G1-15].
  • Associated systolic murmur: Mid-systolic ejection aortic murmur due to transaortic volume hyperflow (functional flow murmur) [V3] [G1-14].
  • Austin Flint murmur: Apical low-frequency mid-diastolic rumble in severe forms due to displacement/vibration of the anterior mitral leaflet struck by the aortic regurgitant jet [V1] [V3] [G1-15].
Arterial pulse
  • In severe forms: Slow-rising pulse with delayed peak (pulsus parvus et tardus / anacrotic pulse) [B4] [V1].
  • In severe forms: Hyperdynamic, bounding, or collapsing pulse with rapid upstroke and swift collapse (pulsus celer et magnus / Corrigan pulse / water-hammer pulse) [B4] [V1].
Jugular venous pulse
  • Generally normal; prominent 'a' wave in the presence of septal hypertrophy reducing RV compliance (Bernheim effect) [B3].
  • Generally normal, unless advanced biventricular congestive heart failure supervenes [B3].
Maneuvers
  • Valsalva maneuver (strain phase): Markedly decreases murmur intensity [B1].
  • Squatting: Increases murmur intensity due to increased venous return and stroke volume [B1].
  • Abrupt standing: Decreases the murmur by reducing preload [B1].
  • Isometric handgrip: Maintains or slightly decreases murmur intensity [B1].
  • Isometric handgrip: Increases peripheral vascular resistance and diastolic gradient [B1].
  • Squatting: Increases the diastolic murmur by raising afterload and preload [B1].
  • Valsalva (strain phase): Significantly decreases murmur intensity [B1].

Sources and bibliographic references

Calcific aortic stenosis

  1. [B1] Bedside diagnosis of systolic murmurs . N Engl J Med (1988) . DOI: 10.1056/NEJM198806163182404 PubMed: 2897627
  2. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  3. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  4. [E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191097 PubMed: 19228820
  5. [E2] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191095 PubMed: 19228822
  6. [G1-01] Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice . J Am Soc Echocardiogr (2009) . DOI: 10.1016/j.echo.2008.11.029 PubMed: 19130998
  7. [G1-11] The Second Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250183
  8. [G1-13] The Fourth Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250185
  9. [G1-14] Systolic Murmurs . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250186
  10. [V1] 2025 ESC/EACTS Guidelines for the management of valvular heart disease . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf194 PubMed: 40878295
  11. [V2] 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines . Circulation (2021) . DOI: 10.1161/CIR.0000000000000923 PubMed: 33332150
  12. [V4] Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography . Eur Heart J Cardiovasc Imaging (2017) . DOI: 10.1093/ehjci/jew335 PubMed: 28363204

Chronic aortic regurgitation

  1. [B1] Bedside diagnosis of systolic murmurs . N Engl J Med (1988) . DOI: 10.1056/NEJM198806163182404 PubMed: 2897627
  2. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  3. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  4. [E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191097 PubMed: 19228820
  5. [G1-11] The Second Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250183
  6. [G1-12] The Third Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250184
  7. [G1-14] Systolic Murmurs . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250186
  8. [G1-15] Diastolic Murmurs . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250187
  9. [V1] 2025 ESC/EACTS Guidelines for the management of valvular heart disease . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf194 PubMed: 40878295
  10. [V3] Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance . J Am Soc Echocardiogr (2017) . DOI: 10.1016/j.echo.2017.01.007 PubMed: 28314623