Test 3 - Valvular disease, congenital defects, ACS

Question 1

You hear a crescendo-decrescendo systolic murmur in a 78 year-old man. What is at the top of your DDx and what is the most likely etiology?

Answer 1

Likely aortic stenosis from degeneration

Question 2

What type of valvular disease is Marfan’s syndrome associated with? How does Marfan’s cause this valvular disease?

Answer 2

Aortic regurgitation. Marfan’s can result in aortic root dilation, which makes it so the aortic valves can’t close tightly

Question 3

Your 24 year-old patient has a low-pitched, rumbling diastolic murmur best heard at the cardiac apex. What is at the top of your DDx what what is the most likely etiology?

Answer 3

Most likely mitral valve stenosis from rheumatic heart disease

Question 4

Name five causes of mitral valve regurgitation.

Answer 4

1. Myxomatous degeneration (weakening of the proteoglycans in the CT)
2. Chordae tendinae rupture
3. Ischemia/infarction of papillary muscles
4. Dilation of the anulus fibrosus
5. Rheumatic heart disease (causes stenosis first that can progress to regurgitation)

Question 5

What are the pathophysiological consequences to the myocardium as a result of aortic stenosis?

Answer 5

Stenosis –> high LV pressure –> high LV wall tension –> concentric hypertrophy –> impaired LV filling –> LA dilation –> a-fib risk and pulmonary congestion

Question 6

What are the pathophysiological consequences to the myocardium as a result of aortic regurgitation?

Answer 6

Increased LV volume and pressure –> LV dilation –> LA dilation –> a-fib risk and pulmonary congestion

Question 7

What are the pathophysiological consequences to the myocardium as a result of mitral stenosis?

Answer 7

Increased LA filling pressure –> LA dilation –> pulmonary hypertension, a-fib risk, thrombus formation risk from stasis in the big LA

Question 8

What are the pathophysiological consequences to the myocardium as a result of mitral regurgitation?

Answer 8

Increased LA pressure –> increased LA size –> a-fib risk

Question 9

Describe the murmur caused by aortic stenosis and where it is best heard.

Answer 9

Crescendo-decrescendo between S1 and S2 (during systole).

Heard best at the 2nd intercostal space just lateral to the sternum.

Question 10

An S4 heart sound is most likely associated with which valvular disease?

Answer 10

Aortic stenosis. Because it causes LV hypertrophy and S4 sounds are heard with hypertrophic, stiff ventricles.

Question 11

What is pulsus parvus et tardus?

Answer 11

Weak and late carotid pulse associated with aortic stenosis

Question 12

What valvular disease is associated with syncope during exercise?

Answer 12

Aortic stenosis

Question 13

What valvular disease is associated with a forceful carotid pulse that suddenly collapses? What is the name for this?

Answer 13

Aortic regurgitation - widened pulse pressure means the carotid can easily collapse during diastole. Corrigan’s pulse

Question 14

What is the significance of head bob (de Muset)?

Answer 14

A sign of aortic regurgitation

Question 15

What extra heart sound could be heard in a patient with aortic regurgitation?

Answer 15

Aortic regurgitation can cause LV dilation –> S3 heart sound

Question 16

Describe the murmur heard in a patient with mitral stenosis.

Answer 16

Low-pitched rumble during diastole, heard at the cardiac apex

Question 17

What is a mid-systolic click suggestive of?

Answer 17

Mitral valve prolapse

Question 18

Your 34 year-old patient comes in complaining of shortness of breath, fatigue, and palpitations. On exam, you note a holosystolic murmur heard at the apex as well as a diastolic murmur, and his PMI is laterally displaced. What is at the top of your DDx and what is the likely etiology?

Answer 18

Likely mitral valve regurgitation from rheumatic disease. Increased LA filling pressure –> LA dilation (risk for a-fib) –> increased volume rushing into the LV during diastole results in the diastolic murmur. The systolic murmur is from the regurgitation.