Used to differentiate between aortic stenosis and mitral prolapse or hypertrophic cardiomyopathy (HCM).

Performing the Test

  1. Position patient supine, and have them bear down while mouth is closed or place a hand on abdomen and have patient strain against you
  2. Bearing down against closed glottis decreased venous return versus release of effort of bearing down will increase venous return
  3. Auscultate during the strain and release phases
  4. During strain:
    MV prolapse = earlier systolic click, longer murmur
    HCM = increased intensity; AS = decreased intensity of murmur


  1. Bickley L, Hoekelman R. Bates’ Guide to Physical Examination and History Taking. Philadephia, Pa: Lippincott; 2009.