How to Differentiate Mitral Regurgitation (MR) vs Aortic Stenosis (AS) on CW Doppler and CW envelope SHAPE

1. Timing

Holosystolic signal (throughout systole).

Starts with isovolumic contraction and ends after A2 sometimes.

No clear envelope edges.

Mid-systolic envelope (starts after IVCT, ends before A2).

Well-defined start and end.

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2. Shape of CW Envelope

Mitral Regurgitation (MR)

Tall, dense, triangular (early-peaking)

“V-shaped” or triangular because MR is often pressure-dependent.

Peak velocity early then falls → early systolic peak (unless severe chronic MR → rounded).

Aortic Stenosis (AS)

Parabolic, rounded, symmetric envelope

“Bullet shape”

Peaks mid-systole (late peak if severe).

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3. Velocity

MR usually has higher velocity (5–6 m/s common).

AS varies depending on severity but usually 3–5 m/s.

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4. Direction & Position of CW Line

MR CW is obtained from the apex directed posteriorly into the LA.

AS CW is obtained in multiple windows (RUP parasternal, apical, suprasternal).

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Summary

Holosystolic

Triangular / V-shaped

Early peak

Very high velocity

Fills entire systole

Mid-systolic

Rounded / parabolic

Mid or late peak

Duration shorter

Does not start at MVC and ends before A2

Comments

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𝘼𝙣𝙩𝙞𝙘𝙤𝙖𝙜𝙪𝙡𝙖𝙩𝙞𝙤𝙣 𝘼𝙛𝙩𝙚𝙧 𝙎𝙩𝙧𝙤𝙠𝙚 in Patient with AF and acute IS/TIA European Heart Association Guideline recommends: • 1 days after TIA • 3 days after mild stroke • 6 days after moderate stroke • 12 days after severe stroke Early anticoagulation can decrease a risk of recurrent stroke and embolic events but may increase a risk of secondary hemorrhagic transformation of brain infarcts. The 1-3-6-12-day rule is a known consensus with graded increase in delay of anticoagulation between 1 and 12 days after onset of ischemic stroke or transient ischemic attack(TIA), according to neurological severity based on European expert opinions. However, this rule might be somewhat later than currently used in a real-world practical setting.

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