MioAtlas
Comparison

Hypertrophic obstructive cardiomyopathy vs Calcific aortic stenosis: clinical and ECG differences

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

Hypertrophic obstructive cardiomyopathy
View full clinical guide Open in 3D simulator
Calcific aortic stenosis
View full clinical guide Open in 3D simulator

Findings by layer and diagnostic parameters

Layer / Finding Hypertrophic obstructive cardiomyopathy Calcific aortic stenosis
Hemodynamics
  • Peak LV outflow tract gradient: L < 30 mmHg, M 30–49 mmHg, G ≥ 50 mmHg [C1] [G5-01].
  • Left ventricular end-diastolic pressure and pulmonary capillary wedge pressure: Elevated in moderate and severe stages due to diastolic dysfunction and hypertrophy [C1] [G5-10].
  • 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].
Rhythm
  • Atrial fibrillation as a common supraventricular arrhythmia associated with elevated left atrial pressures [C1] [G5-01].
  • Normal sinus rhythm [V1].
  • In advanced stages or calcification extending to the AV node: possible atrial fibrillation or conduction disturbances [E2] [V1].
ECG
  • Left ventricular hypertrophy voltage criteria (left ventricular hypertrophy voltage criteria, positive Sokolow-Lyon / Cornell) accompanied by secondary ventricular repolarization abnormalities / systolic overload (LV systolic overload pattern) [E1] [C1].
  • Pathological pseudo-infarct Q waves (pseudoinfarct Q waves): Deep, narrow Q waves (< 40 ms) in inferolateral leads (I, aVL, V4–V6, II, III, aVF) resulting from initial depolarization forces of the massively thickened septum [C1] [G5-01] [G5-10].
  • 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].
Heart sounds and murmurs
  • Ejection mesosystolic murmur: Harsh diamond-shaped (crescendo-decrescendo) systolic murmur, loudest at lower left sternal border and apex; characteristically does not radiate to neck / carotids (key clinical distinction from fixed aortic stenosis) [B1] [G5-10] [G1-14].
  • Mitral regurgitation murmur: Accompanying apical holosystolic murmur of mitral incompetence due to SAM, with regurgitant jet directed eccentrically posterolaterally [G5-11].
  • Fourth heart sound (S4): Prominent presystolic atrial gallop at apex due to atrial contraction against a stiff, poorly compliant ventricle [G1-13] [G5-10].
  • 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].
Arterial pulse
  • Carotid pulse with spike-and-dome contour (pulsus bisferiens / spike-and-dome): Rapid, brisk initial upstroke corresponding to initial pre-obstructive ejection, followed by a mid-systolic dip due to dynamic obstruction and a second, more sustained late rise [B4] [G5-10].
  • In severe forms: Slow-rising pulse with delayed peak (pulsus parvus et tardus / anacrotic pulse) [B4] [V1].
Jugular venous pulse
  • Prominent 'a' wave: Caused by increased resistance to right ventricular filling when the hypertrophied septum bulges into the RV lumen (Bernheim effect) [B3] [G5-10].
  • Generally normal; prominent 'a' wave in the presence of septal hypertrophy reducing RV compliance (Bernheim effect) [B3].
Maneuvers
  • Valsalva maneuver (strain phase): Markedly increases murmur intensity by reducing preload and ventricular end-diastolic volume, narrowing the LVOT and accentuating SAM [B1] [G5-10].
  • Abrupt standing: Increases the murmur by decreasing preload [B1].
  • Squatting: Decreases murmur intensity by increasing venous return and arterial afterload, widening the LVOT cavity [B1].
  • Isometric handgrip: Decreases murmur intensity by increasing systemic vascular resistance (afterload), moving the anterior mitral leaflet away from the septum [B1].
  • 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].

Sources and bibliographic references

Hypertrophic obstructive cardiomyopathy

  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. [C1] 2023 ESC Guidelines for the management of cardiomyopathies . Eur Heart J (2023) . DOI: 10.1093/eurheartj/ehad194 PubMed: 37622657
  5. [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
  6. [G1-13] The Fourth Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250185
  7. [G1-14] Systolic Murmurs . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250186
  8. [G5-01] 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines . Circulation (2020) . DOI: 10.1161/CIR.0000000000000937 PubMed: 33215931
  9. [G5-10] Hypertrophic cardiomyopathy . Lancet (2013) . DOI: 10.1016/S0140-6736(12)60397-3 PubMed: 22874472
  10. [G5-11] Systolic anterior motion begins at low left ventricular outflow tract velocity in obstructive hypertrophic cardiomyopathy . J Am Coll Cardiol (2000) . DOI: 10.1016/s0735-1097(00)00830-5 PubMed: 11028493

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