6.1 MTB Step 3 - Valvular Heart Disease (Murmurs) Flashcards
GENERAL INFORMATION
What does ALL Valvular Heart Disease present with as the Chief Complaint?
Shortness of Breath (SOB), worse with Exertion/Exercise.
GENERAL INFORMATION
What are (5) Disorders/Causes that will be in the patient’s History but, with the exception of one, are probably too nonspecific to give the diagnosis of VHD?
- Hypertension (HTN)
- Myocardial Infarction (MI)
- Ischemia
- Increasing Age
- Rheumatic Fever - unlike the other conditions, this diagnosis with make the co-diagnosis of VHD clear
GENERAL INFORMATION
Young patients with Valvular Heart Disease will have one of which (4) Types?
-
Mitral Valve Prolapse (MVP)
- Young female, general population.
- Palpitations, Atypical Chest Pain not with exertion.
-
Hypertrophic Obstructive Cardiomyopathy (HOCM)
- Health young athlete.
-
Mitral Stenosis
- Immigrant or Pregnant = think Rheumatic Heart Disease.
-
Bicuspid Aortic Valve
- Turner Syndrome, Coarctation of Aorta.
PHYSICAL FINDINGS
- ALL Valvular Heart Disease can be EXPECTED to have which (2) Findings on Physical Exam?
- What are (3) POSSIBLE Findings on Physical Exam in ALL Valvular Heart Disease?
EXPECTED Findings on PE:
- Murmurs
- Rales
POSSIBLE Findings on PE:
- Peripheral Edema
- Carotid Pulse findings
- Gallops
MURMURS
What are (4) Systolic Murmurs related to Valvular Heart Diseases?
- Mitral Regurgitation
- Aortic Stenosis
- Mitral Valve Prolapse (MVP)
- Hypertrophic Obstructive Cardiomyopathy (HOCM)
MURMURS
What are (2) Diastolic Murmurs related to Valvular Heart Diseases?
- Mitral Stenosis
- Aortic Regurgitation
MURMURS
All Right-sided Murmurs INCREASE in Intensity with what?
Inhalation
Both Stenosis and Regurgitation of Tricuspid valve
MURMURS
All Left-sided Murmurs INCREASE in Intensity with what?
Exhalation
Mitral and Aortic valve lesions
VALSALVA, STANDING, SQUATTING, LEG RAISE
Which (2) Maneuvers INCREASE Venous Return to the Heart?
- Squatting
- Leg Raise
VALSALVA, STANDING, SQUATTING, LEG RAISE
Which (2) Maneuvers DECREASE Venous Return to the Heart?
- Valsalva = increases intrathoracic pressure
- Standing
VALSALVA, STANDING, SQUATTING, LEG RAISE
Which Murmurs INCREASE in Intensity (get Louder) with Squatting and Leg Raise?
- Aortic Stenosis (AS)
- Aortic Regurgitation (AR)
- Mitral Stenosis (MS)
- Mitral Regurgitation (MR)
- All Right-sided lesions
VALSALVA, STANDING, SQUATTING, LEG RAISE
Which Murmurs DECREASE in Intensity (get Quieter) with Squatting and Leg Raise?
- Mitral Valve Prolapse (MVP)
- Hypertrophic Obstructive Cardiomyopathy (HOCM)
VALSALVA, STANDING, SQUATTING, LEG RAISE
Which Murmurs INCREASE in Intensity (get Louder) with Valsalva and Standing?
- Mitral Valve Prolapse (MVP)
- Hypertrophic Obstructive Cardiomyopathy (HOCM)
VALSALVA, STANDING, SQUATTING, LEG RAISE
Which Murmurs DECREASE in Intensity (get Quieter) with Valsalva and Standing?
- Aortic Stenosis (AS)
- Aortic Regurgitation (AR)
- Mitral Stenosis (MS)
- Mitral Regurgitation (MR)
- All Right-sided lesions
EFFECTS OF HANDGRIP AND AMYL NITRATE
- What is the Effect of Handgrip on Afterload?
- Which Murmurs INCREASE in Intensity with Handgrip?
- Increases Afterload by compressing the arteries of the arm by contracting the muscles of the arm.
- Aortic Regurgitation, & Mitral Regurgitation by pushing blood backward into the heart. VSD because more blood now goes from the LV into the RV.
EFFECTS OF HANDGRIP AND AMYL NITRATE
- What is the Effect of Amyl Nitrate on Afterload?
- Which Murmurs INCREASE in Intensity with Amyl Nitrate?
- Decreases Afterload by dilating peripheral arteries (like giving an ACEI.
- Mitral Valve Prolapse (MVP) by increasing the degree of prolapse of the valves. Hypertrophic Obstructive Cardiomyopathy (HOCM) by increasing the obstruction.
EFFECTS OF HANDGRIP AND AMYL NITRATE
Which Murmurs DECREASE in Intensity with Amyl Nitrate?
- Aortic Regurgitation
- Mitral Regurgitation
EFFECTS OF HANDGRIP AND AMYL NITRATE
Which Murmurs DECREASE in Intensity with Handgrip?
- Mitral Valve Prolapse (MVP)
- Hypertrophic Obstructive Cardiomyopathy (HOCM)
- These murmurs lessen when the LV chamber is Larger or More Full.*
- When Afterload is increased the LV chamber will not empty and, therefore, the LV will be Larger.*
- A Larger LV chamber relieves or lessens the obstruction in HOCM.*
LOCATION AND RADIATION OF MURMURS
Aortic Stenosis (AS)
- 2nd RIGHT Intercostal space
- Radiates to Carotic Arteries
LOCATION AND RADIATION OF MURMURS
Pulmonic Valve Murmurs
2nd LEFT Intercostal space
LOCATION AND RADIATION OF MURMURS
Aortic Regurgitation, VSD, and Tricuspid murmurs
Lower Left Sternal border
LOCATION AND RADIATION OF MURMURS
Mitral Regurgitation (MR)
Apex and Radiates into the Axilla
INTENSITY OF MURMURS
What is considered I/VI Murmur Intensity?
Only Heard with Special Maneuvers (e.g., Valsalva, Handgrip)
INTENSITY OF MURMURS
What is considered II/VI and III/VI Murmur Intensity?
Majority of Murmurs (no objective difference between them)
INTENSITY OF MURMURS
What is considered IV/VI Murmur Intensity?
Thrill present (a palpable vibration from severe valve lesion)
INTENSITY OF MURMURS
What is considered V/VI Murmur Intensity?
Heard without a stethoscope partially off the chest
INTENSITY OF MURMURS
What is considered VI/VI Murmur Intensity?
No Stethoscope needed to hear
INTENSITY OF MURMURS
- What is the Best INITIAL Test for Valve Lesions?
- What is the Most ACCURATE Test for Valve Lesions?
- Echocardiogram
- Left Heart Catheterization (can also measure pressure gradients, such as in aortic stenosis, most accurately)
**On CCS cases, also add an ECG and CXR to the assessment**
INTENSITY OF MURMURS
What is the Best INITIAL Treatment for REGURGITANT Lesions?
Vasodilator Therapy, such as ACEIs, ARBs, or Nifedipine
- Afterload Reducers that slow progression.*
- If* patient still progresses despite medical therapy, then surgical replacement of the valve should be performed.
INTENSITY OF MURMURS
What is the Best Type of Treatment for STENOTIC Lesions?
Anatomic Repair
Mitral Stenosis should undergo Balloon Valvuloplasty, even if the patient is Pregnant.
Aortic Stenosis that is severe must be Surgically Replaced (well tolerated even in the old.
Pulmonary Vascular Congestion can be decreased with Diuretics, but they are NOT as important as Anatomic Repair
INTENSITY OF MURMURS
On CCS, what Test should you order if the TTE is not fully diagnostic?
TEE
INTENSITY OF MURMURS
What Medication is indicated if Valsalva improves murmur?
Diuretic
INTENSITY OF MURMURS
What Medication is indicated if Amyl Nitrate improves murmur?
ACE Inhibitor
