Valves & Murmurs

Question 1

What type of murmur does aortic stenosis produce and where do you listen to it?

Answer 1

• Ejection systolic

- 2nd intercostal space, right sternal edge/border

Question 2

Where does aortic stenosis murmur radiate to?

Answer 2

Carotid radiation

Question 3

What type of murmur does mitral regurgitation/insufficiency produce and where do you listen to it?

Answer 3

• Pansystolic (holosystolic)

- 5th intercostal space, mid clavicular line i.e. apex (PMI)

Question 4

Where does mitral regurgitation murmur radiate to?

Answer 4

Axilla radiation

Question 5

What type of murmur does aortic regurgitation produce and where do you listen to it?

Answer 5

• Early diastolic

- 2nd intercostal space, right sternal edge/border

Question 6

What type of murmur does mitral stenosis produce and where do you listen to it?

Answer 6

• Mid-diastolic

- 5th intercostal space, mid clavicular line i.e. apex (PMI)

Question 7

What two murmurs have a descrescendo?

Answer 7

Aortic regurgitation and mitral stenosis

Question 8

How do you accentuate a right heart murmur?

Answer 8

Inspiration

Question 9

How do you accentuate a left heart murmur?

Answer 9

Expiration

Question 10

How do you diagnose valve disease

Answer 10

Echocardiogram (Echo) (+ doppler)

Question 11

What other investigation might you do to diagnose mitral regurgitation?

Answer 11

Cardiac catheterisation

Question 12

What two investigations might you do in someone with suspected valve disease?

Answer 12

ECG, CXR

Question 13

What age group of patients typically get aortic stenosis?

Answer 13

Elderly (>60)

Question 14

What are the 4 causes of aortic stenosis?

Answer 14

1) Senile calcification
2) Rheumatic fever
3) Bicuspid valve (congenital)
4) William’s syndrome (congenital)

Question 15

What are the symptoms and signs of aortic stenosis?

Answer 15

1) Angina
2) Exertional dyspnoea (heart failure)
3) Syncope
4) Symptoms of LVF - HF, stroke, arrhythmias
5) Slow rising pulse
6) Paradoxically split S2
7) Narrow pulse pressure

Question 16

How do you treat aortic stenosis and aortic regurgitation?

Answer 16

Valve replacement

Question 17

How do you treat aortic stenosis if the pt is unfit for surgery?

Answer 17

TAVI/valvuloplasty

Question 18

When would you use a biological valve?

Answer 18

Older patients (lower chance of clots and rejection)

Question 19

When would you use a mechanical valve?

Answer 19

Younger patients (<50) (lasts longer)

Question 20

What is the most common cause of mitral regurgitation?

Answer 20

Mitral valve prolapse

Question 21

What cardiac condition is mitral regurgitation associated with?

Answer 21

AF

Question 22

What are other causes of mitral regurgitation?

Answer 22

1) LV dilation - AR, AS, HTN
2) Senile annular calcification
3) Papillary muscle dysfunction/rupture (POST-MI)
4) Rheumatic fever
5) Infective endocarditis
6) Connective tissue disease i.e. Marfan’s/Ehler-Danlos

Question 23

What are the symptoms of mitral regurgitation

Answer 23

1) Dyspnoea
2) Fatigue
3) Palpitations (AF)

Question 24

What should you do first in management of valve disease?

Answer 24

Monitor and treat cardiovascular risk factors e.g. BP

Question 25

How do you monitor valve disease?

Answer 25

Echo

Question 26

What are 3 causes of mitral stenosis?

Answer 26

1) Rheumatic fever
2) Congenital
3) Prosthetic valve

Question 27

What are causes of acute aortic regurgitation?

Answer 27

1) Infective endocarditis
2) Ascending aortic dissection
3) Chest trauma

Question 28

What are causes of chronic aortic regurgitation?

Answer 28

1) Rheumatic fever
2) Connective tissue disease i.e. Marfan’s, Ehlers-Danlos
3) Congenital
4) Takayasu arteritis
5) Arthritides

Question 29

What are the symptoms of aortic regurgitation?

Answer 29

1) Exertional dyspnoea
2) Orthopnoea
3) Paroxysmal nocturnal dyspnoea

Question 30

What are the signs of aortic regurgitation?

Answer 30

1) End-diastolic murmur
2) Collapsing water-hammer pulse/Corrigan’s sign
3) Wide pulse pressure
4) Displaced apex beat

Question 31

What type of valve disease occurs post-MI?

Answer 31

Mitral regurgitation

Question 32

What types of valve disease occurs from connective tissue disease i.e. Marfan’s/Ehlers-Danlos

Answer 32

Regurgitation - aortic or mitral

Question 33

What are the signs of mitral regurgitation?

Answer 33

1) Pansystolic murmur + axilla radiation
2) Displaced apex
3) AF

Question 34

How do you treat AF (in mitral regurgitation)?

Answer 34

Rate control and anticoagulation

Question 35

What anticoagulation drugs are given in AF?

Answer 35

Apixaban, dabigatran, rivaroxaban, warfarin (vit K antagonist)

Question 36

What rate control drugs can be given in AF?

Answer 36

Beta blockers e.g. bisoprolol

Calcium channel blockers e.g. verapamil

Question 37

How do you treat mitral regurgitation?

Answer 37

Valvuloplasty/Valve replacement ± diuretics (symptomatic)

Question 38

What infectious disease can cause aortic regurgitation?

Answer 38

Syphilis

Question 39

Where do you listen to the pulmonary valve?

Answer 39

2nd ICS left sternal border

Question 40

Where do you listen to the tricuspid valve?

Answer 40

5th ICS to the lower left sternal border

Question 41

Where is Erb’s point?

Answer 41

3rd ICS to the left sternal border

Question 42

What murmurs can be heard at Erb’s point?

Answer 42

• Diastolic murmurs - aortic regurgitation, pulmonic regurgitation
• Systolic murmurs - HCOM

Question 43

What causes a paradoxically split S2 sound?

Answer 43

• Aortic stenosis
• Atrial septal defect
• HOCM
• LBBB

Question 44

What causes a narrow pulse pressure?

Answer 44

• HF
• Blood loss
• Aortic stenosis
• Cardiac tamponade