Clinical features

Possible symptoms include:

• angina
• dyspnoea
• palpitations
• syncope
• sudden death

Clinical signs include:

• jerky pulse
• JVP: large a waves, indicating right ventricular flow obstruction
• double impulse at apex
• loud fourth heart sound due to the left ventricular hypertrophy
• third heart sound
• late systolic murmur:
  • this is a result of outflow tract obstruction with or without mitral regurgitation
  • the murmur is late in systole because some blood must be ejected from the ventricle before the outflow is obstructed
  • the murmur is louder during a Valsalva manoeuvre
  • the murmur is softer when squatting