The Critical Vector · Valvular Heart Disease

Bedside Signs You Must Not Miss

Cardiology exam skills. Part 1 of 2 — Mitral Stenosis, Mitral Regurgitation, Aortic Stenosis. Verified against the 2025 ESC/EACTS VHD Guidelines and Braunwald's, 12th ed. September 2026.

VERIFIED: the 2025 ESC/EACTS VHD Guidelines are a real, current document (update to the 2021 guideline, presented ESC Congress Madrid, Aug 2025). The "~45% GP sensitivity" figure traces to a real dataset — 46.2% traditional-stethoscope sensitivity vs. 92.3% AI-assisted, in a 357-patient primary-care study (Eur Heart J Digital Health, Feb 2026).
INCOMPLETE SOURCE: the original carousel runs 17 slides covering all six valve lesions plus eponymous mimics and prosthetic-valve sounds. Only slides 1–5 were captured (framework + MS, MR, AS). Aortic Regurgitation, Tricuspid Disease, Pulmonic Valve Disease, and the mimics/prosthetics slides are pending for Part 2.
01

The Bedside Framework

1. General exam: facies, cyanosis, clubbing, pulse character/volume, JVP, peripheral edema.

2. Precordial exam: apex beat location/character, heaves, thrills, palpable sounds.

3. Auscultation: murmur timing, character, radiation, dynamic maneuvers (Valsalva, hand-grip, squat).

Exam alone misses roughly half of significant VHD — a low threshold for echo referral is essential, but the exam still tells you what to look for.

02

Mitral Stenosis

Valve 1 of 6
DomainFindings
InspectionMalar flush / mitral facies; peripheral cyanosis (lips, nose tip)
PalpationTapping apex beat (palpable S1); left parasternal heave (RVH from pulmonary hypertension); diastolic thrill at apex, left lateral position
Pulse / JVPOften irregularly irregular (AF common); prominent 'a' wave if still in sinus rhythm
AuscultationLoud S1; opening snap after S2 — shorter S2–OS interval = more severe; low-pitched rumbling diastolic murmur at apex, best heard left lateral with the bell, accentuated by exercise

Severity red flags: shorter S2–OS gap · longer murmur duration · signs of pulmonary hypertension (loud P2, RV heave) · new AF

03

Mitral Regurgitation

Valve 2 of 6
DomainFindings
InspectionSigns of LV failure if decompensated; visible hyperdynamic apical impulse
PalpationApex beat displaced, hyperdynamic/thrusting; systolic thrill at apex (severe MR); left parasternal heave (LA enlargement pushing RV)
PulseOften normal volume; sharp upstroke; AF common in chronic MR
AuscultationSoft/absent S1; pansystolic murmur at apex radiating to axilla; widely split S2; S3 gallop (high flow, not always LV dysfunction); louder on expiration, left lateral position

Severity red flags: presence of S3 · displaced hyperdynamic apex · early-peaking systolic murmur

Don't be falsely reassured: acute severe MR can be soft or short — a quiet murmur does not rule out severe disease.

04

Aortic Stenosis

Valve 3 of 6

Symptom triad: angina, syncope (exertional), dyspnea — each additional symptom drops survival further.

DomainFindings
PalpationSustained, heaving apex beat (not displaced until late disease); systolic thrill at aortic area/carotids; slow-rising carotid upstroke
PulsePulsus parvus et tardus; low pulse pressure; narrow pulse pressure in severe AS
AuscultationHarsh ejection systolic murmur, crescendo–decrescendo, radiates to carotids; soft/absent A2 in severe AS; Gallavardin phenomenon — musical/high-frequency component at the apex that can mimic MR; paradoxically split S2

Severity red flags: soft/inaudible A2 · late-peaking murmur · slow carotid upstroke · any syncope or angina — these change management urgency

05

Primary Sources

  • 2025 ESC/EACTS Guidelines for the Management of Valvular Heart Disease (update to the 2021 document; presented ESC Congress, Madrid, Aug 2025).
  • Braunwald's Heart Disease, 12th ed.
  • McDonald A, et al. Development and validation of AI-enhanced auscultation for valvular heart disease screening through a multi-centre study. npj Cardiovasc Health. 2026. doi:10.1038/s44325-026-00103-y
  • Artificial-intelligence-enabled digital stethoscope improves point-of-care screening for moderate-to-severe valvular heart disease. Eur Heart J Digit Health. 2026 (ESC news release, Feb 5, 2026).
  • Merck Manual; GP Notebook (secondary/tertiary references, as cited in the original carousel).