Valvular heart disease Flashcards
Types of murmurs
Systolic; ‘a systolic murmur, really tiring respiration’
- AS: aortic stenosis
- MR: mitral regurgitation
- TR: triscuspid regurgitaton
Diastolic; ‘a regurg. makes SOB’
- AR: aortic regurgitatoin
- MS: mitral stenosis
How may breathing make murmurs louder?
On expiration = left-sided murmurs louder
- mitral, aortic
On inspiration = right-sided murmurs louder
- tricuspid
Valsalva manoeuvre = increase HOCM + mitral valve prolapse
- force exhalation against closed airway (pinch nose and breath out)
Aortic stenosis summary card
Narrowing of LV outflow at aortic valve
= age-related calcification, congenital bicuspid aortic valve, CTD, rheumatic heart disease
= O/E: BP w/ narrow pulse pressure, slow-rising pulse, palpable thrill (palpable heart murmur)
= EJECTION systolic murmur; ask pt to hold breath on expiration to accentuate murmur, can radiate to carotids and apex
Mitral regurgitation summary card
Backflow of blood from LV -> LA
= CTD, rheumatic heart disease, congenital
= O/E: normal/irregularly irregular pulse, palpatation, palpable laterally displaced apex beat
= PAN systolic murmur; louder on expiration as increased venous return from pulmonary veins to left heart, radiates to axilla
Triscuspid regurgitation summary card
Backflow of blood from RV -> RA
= infective endocarditis (?IVDU), rheumatic heart disease, CTD, congenital
= O/E: raised JVP, palpable parasternal heave, RHF signs - pleural effusion, hepatomegaly, ascites, pitting oedema
= PAN systolic murmur; ask pt to hold breath on inspiration to accentuate murmur (Carvallo’s sign)
Sx of valvular heart disease
Palpitations, SOB, syncope on exertion, heart failure signs, angina, orthopnoea
Ix findings for systolic murmurs
ECG
= AS; left axis deviation, enlarged R waves, T wave inversion
= TR; tall p-wave
CXR = enlargement of ascending aorta = AS; aortic valve calcification = MR; cardiomegaly = TR; right-sided enlargement
Aortic regurgitation summary card
Reflux of blood from aorta to LV
= infective endocartitis, rheumatic heart disese, congenital bicuspid aortic valve, dilation of aorta (HTN, aortitis)
= O/E: BP w/ wide pulse pressure, collapsing pulse (like a ‘water hammer’/Corrigan’s pulse), palpable displaced apex beat
= EARLY diastolic murmur; ask pt to sit forward and hold breath on expiration, radiates to carotids and apex
Mitral stenosis summary card
Narrowing of mitral valve, obstructing blood flow from LA -> LV
= infective endocartitis, rheumatic heart disese, congenital bicuspid aortic valve, dilation of aorta (HTN, aortitis)
= O/E: malar flush, ‘thready’/irregularly irregular pulse, palpable tapping apex, parasternal heave
= MID-diastolic murmur; loud first HS w/ opening snap, bell of stethoscope may be used
Ix findings for diastolic murmurs
ECG
= signs of LV hypertrophy
= MS; broad bifid p-waves, AF
CXR
= dilation of ascending aorta
= cardiomegaly
Which murmur belongs to which valvular problem?
a) Pan-systolic loudest on inspiration
b) Mid-diastolic
c) Ejection systolic
d) Pan-systolic loudest on expiration
e) Early diastolic
a) Tricuspid regurgitation
b) Mitral stenosis
c) Aortic stenosis
d) Mitral regurgitation
e) Aortic regurgitation
A 49-year-old woman presents with increasing shortness of breath on exertion developing over the past three months. She has no chest pain or cough, and has noticed any ankle swelling. On examination, blood pressure is 158/61mmHg, pulse is regular at 88 beats per minute and there are crackles at both lung bases. There is a diastolic murmur at the left sternal edge. What is the most likely diagnosis?
A. Aortic regurgitation B. Aortic stenosis C. Mitral regurgitation D. Mitral stenosis E. Tricuspid regurgitation
A. Aortic regurgitation
You see a 57-year-old woman who presents with worsening shortness of breath coupled with decreased exercise tolerance. She had rheumatic fever in her adolescence and suffers from essential hypertension. On examination, she has a murmur heard loudest over the mitral area. Which of the following is not a clinical sign associated with the most likely diagnosis?
A Malar flush B. Atrial fibrillation C. Pan-systolic murmur which radiates to axilla D. Tapping, undisplaced apex beat E. Right ventricular heave
C. Pan-systolic murmur which radiates to axilla
diagnosis is mitral stenosis
An 8 year old boy comes to the GP with his mother for a check-up. You find the child to be extremely sociable and friendly, with some mild learning difficulties. You also note distinct facial features including a broad forehead, short nose and full cheeks. On auscultation of his chest, you detect a murmur in the right 2nd intercostal space, loudest on expiration. What is the most likely diagnosis?
A. Hypertrophic Obstructive Cardiomyopathy B. Infective endocarditis C. Aortic stenosis D. Aortic regurgitation E. Mitral stenosis
C. Aortic stenosis
Which of the following does not cause a systolic murmur?
A Atrial septal defect B Ventricular septal defect C Hypertrophic obstructive cardiomyopathy (HOCM) D Aortic regurgitation E None of the above
D Aortic regurgitation
You perform a cardiovascular examination on an elderly gentleman who reports episodes of collapsing and often wakes up short of breath at night.
Upon auscultation you discover an ejection systolic murmur, which radiates to the carotids.
Which is the most likely valvular pathology?
A Aortic stenosis B Aortic regurgitation C Mitral regurgitation D Tricuspid regurgitation E Mitral stenosis
A Aortic stenosis
A 53-year-old woman with Atrial Fibrillation is reviewed by her cardiologists.
On inspection the patients cheeks appear quite flushed. Auscultation reveals a very loud S1 and a mid diastolic murmur.
Which is the most likely valvular pathology?
A Mitral stenosis B Graham Steele C Mitral regurgitation D Aortic regurgitation E Austin Flint
A Mitral stenosis
- Graham Steele is associated w/ pulmonary regurgitation
- Austin Flint is associated w/ aortic incompetence
49-year-old women presents with 3 month history of increasing SOB on exertion. She has no chest pain, cough or ankle swelling.
On examination: BP 158/61 and there are crackles at the bases of both lungs.
On auscultation you hear a diastolic decrescendo murmur loudest at the left sternal edge.
Which is the most likely valvular pathology?
A Aortic regurgitation B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Tricuspid regurgitation
A Aortic regurgitation
Which sign is commonly associated with a valvular condition where the murmur is heard louder during expiration, and softer during the Valsalva manoeuvre, and typically radiated to the carotid?
A Water hammer (collapsing pulse) B Flushed cheek (malar rash) C Displaced apex beat D Slow-rising pulse E Subcutaneous nodules
D Slow-rising pulse
diagnosis is aortic stenosis
Narrow PP, heaving/thrusting undisplaced apex beat
Soft 2nd heart sound
ESM heard aortic area radiating to carotids
Diagnosis?
Aortic stenosis – exertional syncope, SOB, angina
Displaced, volume overloaded apex beat (thrusting)
Soft 1st heart sound
Blowing PSM at apex radiating to axilla
Diagnosis?
Mitral regurgitation
Wide pulse pressure
Displaced, volume overload apex beat
EDM at LSE – best heard leaning forward at expiration
Diagnosis?
Aortic regurgitation
Tapping apex beat + malar flush
Loud 1st heart sound
Rumbling MDM at apex (louder in left lateral position at expiration)
Diagnosis?
Mitral stenosis
PSM LLSE best heard at inspiration
L parasternal heave, pulsatile liver
Increased JVP to ear lobe, hepatomegaly, IVDU
Diagnosis?
Tricuspid regurgitation
Low-pitched, rumbling, mid-diastolic murmur
Austin Flint murmur
= aortic regurgitation
Mid-systolic click and end-systolic murmur at apex
Barlow murmur
= mitral valve prolapse
Mid-diastolic murmur
Carey-Coombs murmur
= thickened mitral valve
Continuous ‘machinery’ murmur
Gibson murmur
= patent ductus arteriousus
High-pitched early diastolic murmur at upper left sternal edge
Graham-Steell murmur
= pulmonary regurgitation
