Snapshot A 75-year-old man, accompanied by his wife, presents to his primary care physician for episodes of chest pain and shortness of breath. He reports that his symptoms occur with exertion and improve with rest. His wife said that a few days ago he passed out for approximately 15 seconds and regained consciousness when laying on the ground. On physical exam, there is a systolic crescendo-decrescendo murmur heart best at the base and radiates to the carotids. (Aortic stenosis) Valvular Diseases Valvular Diseases Type Etiology Murmur Comments Aortic stenosis Age-related calcification in the elderly Bicuspid aortic valve in the young leads to early calcification of the valve Systolic murmur crescendo-decrescendo murmur radiates to the carotids heard best at the base Symptoms syncope angina dyspnea on exertion Patients may develop arrhythmias Pulsus parvus et tardus Mitral regurgitation Rheumatic fever Endocarditis Post-myocardial infarction rupture of the chordae or papillary muscles Left ventricular dilatation Holosystolic murmur high-pitched and radiates towards the axilla heard best at the apex Maneuvers ↑ murmur intensity hand grip rapid squatting -- Tricuspid regurgitation Right ventricular dilatation Rheumatic fever Endocarditis Holosystolic murmur heard best in the tricuspid area Can be seen in patients with a history intravenous drug use Mitral valve prolapse Myxomatous degeneration may be due to Marfan or Ehlers-Danlos syndrome idiopathic over-production of dermatan sulfate Rheumatic fever Systolic murmur late systolic crescendo murmur with a mid-systolic click heard best over the apex Symptoms nonspecific and includes palpitations dizziness dyspnea anxiety Aortic regurgitation Aortic root dilatation Bicuspid aortic valve Endocarditis Rheumatic fever Diastolic murmur early diastolic decrescendo murmur Austin Flint murmur apical diastolic rumbling Maneuvers ↑ murmur intensity hand grip rapid squatting When severe and chronic patients can develop wide-pulse pressure hyperdynamic pulse head bobbing Compensatory increases in heart rate and stroke volume to maintain cardiac output Mitral Stenosis Rheumatic fever Diastolic murmur open snap (OS) and delayed rumbling mid-to-late diastolic murmur the time between A2 and OS is inversely correlated with severity Left atrium can become dilated may compress the esophagus and left recurrent laryngeal nerve may result in atrial fibrillation