A 24-year-old male presents with chest pain, dyspnea on exertion and episodes of syncope while playing. His family history is significant for similar illness in his brother who died suddenly while playing.
Physical Examination: Double peaked pulse (bisferiens pulse), Loud S4; A systolic murmur heard over lower left sternal border. The murmur increases by Valsalva but decreases by squatting and passive leg raising.
EKG: Left axis deviation due to LV hypertrophy
Echo: Asymmetrical septal hypertrophy with marked thickening of the LV septal wall
hypertrophic obstructive cardiomyopathy
How does standing and the Valsalva maneuver affect the murmur in hypertrophic obstructive cardiomyopathy?
increases murmur intensity
- decreased preload leads to greater obstruction
- maneuver decreases venous return
How does standing and the Valsalva maneuver affect the murmur in aortic stenosis?
decrease in murmur intensity
- less volume of blood flows across the stenotic aortic valve
- maneuver decreases venous return
A 45-year-old salesman is referred for evaluation of a heart murmur. He had applied for a pilot's license and was denied because of the murmur. He is asymptomatic and physically active. There is no history of chest pain, dyspnea, or spells of syncope. He has no family history of heart disease. He has never had high blood pressure or diabetes, doesn't smoke, and takes no medications. He had suffered from infective endocarditis when he was 40 year old.
BP - 148/44 mmHg; Pulse - 78 bpm, reg;
Carotids: Very brisk with sharp collapse
Pulses are all very prominent and brisk; audible pulse over the femoral arteries.
JVP: 5 with normal 'a' and 'v' waves
Palpation: Apical impulse is in the 6th intercostal space,
in the anterior axillary line. Auscultation: S1 and S2 are soft;
An early diastolic blowing murmur, heard best at the lower left sternal border;
An early systolic ejection murmur heard at the upper right sternal border.
Describe the findings in aortic regurgitation for the following tests:
List 3 disorders that can cause aortic regurgitation.
What pattern of hypertrophy is associated with aortic regurgitation?
Comment on the following in aortic insufficiency:
LV end-diastolic volume
LV end-diastolic pressure
aortic diastolic pressure
aortic pulse pressure
increased LV end-diastolic volume
increased LV end-diastolic pressure
decreased aortic diastolic pressure
widened aortic pulse pressure
List 2 clinical manifestations (s/s) of aortic regurgitation.
shortness of breath (pulmonary edema)
What type of valvular disorder is associated with aortic aneurysm?
List 3 connective tissue heritable disorders that can cause aortic regurgitation.
List 3/5 inflammatory disorders that can cause aortic regurgitation.
Aortic dissection is associated with which valvular disorder?
What valvular disorder is associated with DeMusset's sign? What is DeMusset's sign?
- head bobbing
What valvular disorder is associated with Muller's sign? What is Muller's sign?
- rhythmic pulsation of the uvula
What valvular disorder is associated with Quincke's pulse? What is Quincke's pulse?
- arterial pulsation seen in the nail bed
Describe the placement and amplitude of the apical impulse in aortic regurgitation.
- increased volume and forceful contraction of LV
Describe the intensities of S1 and S2 in aortic regurgitation.
soft S1 and S2
- S2 soft due to incomplete closure
- S1 soft because of early mitral valve closure from aortic regurgitation and elevated ventricular pressures
Describe the pitch and timing of the hallmark murmur in aortic regurgitation. Where is it best heard?
high-pitched, blowing, decrescendo early diastolic murmur best heard along the left sternal border
Patient presents with a crescendo-decrescendo, early systolic murmur at the right upper sternal border with radiation into the neck.
- due to an increased stroke volume flowing across the aortic valve
- not the hallmark murmur
Identify the name of the murmur. Identify the associated valvular disorder:
Austin Flint murmur
- caused by regurgitant flow from the aortic valve impinging on the anterior leaflet of the mitral valve producing functional mitral stenosis
List 4 types of mitral stenosis.
What is the normal mitral valve area? Give the values for mild, moderate, and severe mitral stenosis.
Is left atrial pressure elevated during ventricular systole or diastole in mitral stenosis?
What is unique about the pressure profile in mitral stenosis?
Review the pressure profile in mitral stenosis.
List 3 s/s of mitral stenosis.
Describe the pitch and timing of mitral stenosis murmur.
low-pitched diastolic rumble in the apex
- diastolic rumble because of turbulent flow across narrowed mitral valve orifice
- opening snap may be heard before diastolic rumble (only heard when leaflets are relatively mobile)
Auscultation reveals bilateral rales. What valvular disorder is implicated?
- elevated pulmonary capillary pressures lead to accumulation of intra-alveolar fluid
What type of fibrillation is associated with mitral stenosis?
What is the most common cause of mitral regurgitation?
mitral valve prolapse
- followed by CAD
List 2 disorders that can cause ruptured chord tendineae leading to acute mitral regurgitation.
acute rheumatic fever
List 3 causes of ruptured or dysfunctional papillary muscles leading to acute mitral regurgitation.
What can cause a perforated mitral leaflet leading to acute mitral regurgitation?
List 3 chronic causes of mitral regurgitation.
-Inflammatory as in Rheumatic heart disease and Collagen vascular disease
-Infection as in Infective endocarditis
-Degenerative as in Myxomatous degeneration of the valve leaflets; Calcification of the mitral annulus
-Rupture or dysfunction of the chordae tendineae or papillary muscles as in Infective endocarditis; Trauma; Acute rheumatic fever; Myocardial infarction
Which heart chamber(s) enlarge in CHRONIC mitral regurgitation?
Which atrial waves are prominent in acute mitral regurgitation?
atrial v waves
Does mitral regurgitation present with elevated left atrial volume and pressure during ventricular diastole or systole?
Describe the pressure gradient between the LA and LV throughout ventricular filling in mitral regurgitation.
no pressure gradient
List 3 s/s of CHRONIC mitral regurgitation.
dyspnea - pulmonary edema
easy fatigability - decreased forward blood flow to the peripheral tissues
palpitations - atrial fibrillation
List 3 s/s of ACUTE mitral regurgitation
shortness of breath
Describe the placement and intensity of the apical pulse in CHRONIC mitral regurgitation.
laterally displaced: compensatory increase in left ventricular volume and wall thickness
hyperdynamic: ventricle now has a low-pressure chamber (LA) into which to eject blood
- acute form does not show such changes
Describe the intensity of S1, S2, and S3 in mitral regurgitation.
muffled S1 and S2
- murmur often obscures both heart sounds
- severe MR or heart failure
List 3 disorders that can cause mitral valve prolapse.
Mitral valve prolapse sex
female > male (3:1)
List 3 s/s of mitral valve prolapse.
atypical chest pain
How does the Valsalva maneuver or standing affect the mitral valve prolapse murmur?
systolic murmur becomes louder and longer
- decreasing venous return
Which sided murmurs increase with inspiration? expiration?
List 2 exceptions to the rule that murmurs decrease in length and intensity during the Valsalva maneuver.
mitral valve prolapse
How does handgrip affect the murmurs of MR, AR, and VSD?
increased due to increase in afterload on LV
How does transient arterial occlusion affect the murmurs of MR, AR, and VSD?
augments the murmurs due to an increase in afterload on LV
- does not affect murmurs due to other causes
How does squatting affect the intensity of most murmurs?
most murmurs become louder
- murmurs of hypertrophic cardiomyopathy and mitral valve prolapse typically soften and may disappear due to increased preload