Murmurs (CM)

Question 0

Causes of aortic stenosis

Answer 0

Degenerative 
Bicuspid valve in the young 
Rheumatic (often with mitral disease)
Atherosclerosis 
Rare (irradiation, collagen disease)

Question 1

Most common cause of valvular disease

Answer 1

Aortic stenosis

Question 2

Symptoms of aortic stenosis

Answer 2

“Congestive failure” bc L ventricular obstruction; dyspnea 50%
Angina 30%
Syncope with exercise intolerance
Death rarely presenting symptom except in kids

Most people are asymptomatic, but once they develop, half die in 2-5yrs

Question 3

Physical exam findings of aortic stenosis

Answer 3

Palpable S4 with heave
Thrill over aortic region
Midsystolic ejection murmur that radiates up neck and along L sternal border
MURMUR GETS QUIETER WITH DISEASE PROGRESSION.

Question 4

Management of asymptomatic aortic stenosis

Answer 4

Get baseline echo
No competitive athletics
Avoid vasodilators (decrease after load and CO)
F/u with echo every 2 or 5 years depending on severity

Question 5

Management of symptomatic aortic stenosis

Answer 5

Once symptoms arise, it is lethal so if they are good surgical risk, valve replacement
Substantial hemodynamic and clinical improvement after procedure

Question 6

Second most common valvular disease

Answer 6

Mitral stenosis

Question 7

Causes of mitral stenosis

Answer 7

Rheumatic fever–almost all mitral stenosis is a complication after. Usually seen in pts 40-50 y.o.

Rare–congenital or non bacterial thrombotic endocarditis

Question 8

Symptoms of mitral stenosis

Answer 8

Symptoms tend to be subtle and slow:
Exercise intolerance 
Congestive failure-edema, orthopnea, DOE, PND 
Hoarseness-recurrent laryngeal nerve
 A fib in elderly
Palpitations as progresses

Question 9

Physical exam findings of mitral stenosis (moderately severe disease)

Answer 9

Sinus rhythm.
Low frequency, mid diastolic rumble heard best at the apex in the L lateral decubitus position
Opening snap after P2
S1 increased and palpable at LSB

Question 10

Physical exam findings of severe mitral stenosis

Answer 10

A fib
Same murmur, no opening snap
R ventricular heave over apex bc fluid backed up in L atria
Maller flush

Question 11

Complications of mitral stenosis

Answer 11

Early stage murmurs are often missed, if suspicious have patient do sit up or valsalva maneuver
As progresses, have L atrial enlargement which can lead to thrombi, especially with a fib
HR is critical to evaluating. As HR increases, there is less time for diastolic filling leading to pulmonary HTN

Question 12

Management of mitral stenosis

Answer 12

Yearly echo
Negative chronotrophs (BB or CCB)
Tx a fib as needed
Low level aerobics to maintain cardio health

Surgical: balloon valvulopasty (early) or replacement (severe)

Question 13

Timing of intervention of pts with mitral stenosis

Answer 13

Definite: clear sxs of heart failure not related to a fib or severe exercise intolerance
Possibly: moderate-severe pulmonary HTN
Non indicated: no symptoms

Question 14

Causes of mitral prolapse

Answer 14

Congenital, autosomal dominant inheritance, connective tissue disorders (Marfans, Duchenne MD, Graves)

Question 15

Symptoms of mitral valve prolapse

Answer 15

Most of the time none

Palpitations most common
Chest pains 
Arrhythmia
 exercise intolerance 
Cerebral emboli and sudden death very rare

Question 16

Physical exam findings of mitral valve prolapse

Answer 16

Murmur: usually late systolic, preceded by click, heard best at apex and LLSB
Opening sound of prolapsed valve returning to position during early diastole
Click and murmur highly variable May need to accentuate with squatting or valsalva
Systolic whoop or honk=Pathognomonic

Question 17

Management of mitral valve prolapse

Answer 17

BB if have sxs consistent with increased sympathetic tone (palpitations), also increases a fib threshold
Exclude any connective tissue disorder
Reassure most are benign
Middle aged males most likely to have mechanical complications

Question 18

Causes of severe chronic aortic regurgitation

Answer 18

degeneration 
bicuspid valve
Rheumatic Heart Disease (with mitral diseae)
trauma 
infectious endocarditis

Question 19

Causes of mild aortic regurgitation

Answer 19

bicuspid valve with severe HTN

Question 20

Causes of acute aortic regurgitation

Answer 20

Chest trauma

Endocarditis

Question 21

Rare causes of aortic regurgitation

Answer 21

Connective tissue disorder

Collagen vascular disorder

Question 22

Symptoms of aortic regurgitation

Answer 22

Acute: dyspnea, orthopnea 
Chronic: worsening exercise intolerance
"Congestive failure"
Angina in only about 5% of patients--worse at night because HR slows
Bounding peripheral pulses

Question 23

Physical Exam findings of aortic regurgitation

Answer 23

Pandiastolic murmur that is blowing, high pitch, heard best of LLSB
With severe disease the PMI can be displaced laterally and to the left

Question 24

Management of aortic regurgitation

Answer 24

Asymptomatic with nl LV systolic function
Need echo a 1-2 years
Vasodilator to maintain EF
High survival rate
If progressive LV dilation or decrease EF, >25% will progress. Sxs with decreased EF and poor functionally capacity–>Need surgery!

Question 25

Causes of mitral regurgitation

Answer 25

Primary: leaflet, annular, or chordae/papillary muscle abnormalities; or mitral valve prolapse
Secondary: LV dilation or endocardial cushion defect from IHD

Question 26

Symptoms of mitral regurgitation

Answer 26

Frequently no symptoms
Ischemic heart symptoms
Exercise intolerance
Palpitations long before congestive failure begins
In severe mitral regurgitation, high atrial pressure causes dyspnea.
May lead to atrial hypertrophy and a fib

Question 27

Physical exam findings in mitral regurgitation

Answer 27

Murmur: systolic, harhs and blowing, high pitched, heard best over apex, and may radiate to left axilla 
Thrill may be palpable at the apex
Large and prominent PMI 
Brisk pulse
LSB heave due to enlarged L atrium

Question 28

Signs of severe mitral regurgitation

Answer 28

Intensity of murmur does not correlate to severity
Evidence of pulmonary HTN and volume overload
EKG: LV hypertrophy, a.fib or BBB

Question 29

Murmur findings that differentiate causes of mitral regurgitation

Answer 29

papillary muscle dysfunction–>crescendo to S2
Mitral valve prolapse–>delayed, preceded by click
posterior ruptured chordae–>mimic aortic stenosis and radiate to 2nd R interspace
anterior ruptured chordae–> radiate to spine and top of head

Question 30

Management of mitral regurgitation

Answer 30

SURGERY is the tx for ANY LV dysfunction
Regurgitant lesions can cause L ventricular damage before sxs occur
Once EF fall below 60% prognosis worsens
Can use ACEI to decrease afterload
Evaluate yearly with color doppler to quantify severity
CXR of moderate to severe show enlarged L atrium and ventricle, and pulmonary congestion
Prognosis for surgery is poor for pts with IHD

Question 31

Cardiac conditions that require prophylactic antibiotics

Answer 31

Hx of endocarditis
Congenital defects
Prosthetic valves
Cardiac transplant recipients with cardiac valvular disease