Key result
Absence of S2 detects severe AS with 89% specificity.
Why the study?
Physical examination is an essential initial tool for diagnosing aortic stenosis, but the accuracy of various physical examination findings in assessing its severity needed evaluation.
Does the absence of the second heart sound (S2) on physical examination accurately identify severe aortic stenosis?
Does the absence of the second heart sound (S2) on physical examination accurately identify severe aortic stenosis?
The absence of the second heart sound on physical examination is a highly specific (89%) clinical sign for identifying severe aortic stenosis, with substantial inter-observer reliability.
Background Physical examination remains the essential initial tool for the diagnosis of aortic stenosis (AS). Objectives This study aimed to evaluate the accuracy of various physical examination findings in assessing the severity of AS. Methods We prospectively enrolled consecutive patients with AS over about a two-year period. Patients were classified as having severe (aortic valve area [AVA] <1cm²) or non-severe (AVA >1cm²) AS based on echocardiographic findings. A cardiologist, blinded to these findings, performed a cardiac physical examination. Subsequently, a second cardiologist, also blinded to prior data, examined the patients to assess inter-observer reliability. Results A total of 220 patients (mean age 78±8 years, 43% women) were included, with 111 (50,5%) diagnosed with severe AS and 109 (49,5%) with non-severe AS (82 moderate and 27 mild AS). Among the physical examination findings, the absence of the second heart sound (S2) demonstrated the highest diagnostic accuracy (0.76; 95% CI, 0.70–0.81; p < 0.001), with a sensitivity of 63%, specificity of 89%, positive predictive value (PPV) of 0.85, and negative predictive value (NPV) of 0.71. The inter-observer reliability for the absence of S2 was substantial (Cohen Kappa 0.66). Conclusions The absence of S2 offers good diagnostic accuracy for distinguishing between moderate and severe AS, highlighting its utility in clinical practice.
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Palma et al. (2026) studied this question. Absence of the second heart sound accurately identifies severe aortic stenosis with a diagnostic accuracy of 0.76, 63% sensitivity, and 89% specificity.
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