Updated: 7/29/2020

Valvular Disease

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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
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
 

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Questions (17)
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(M1.CV.17.4726) A 73-year-old man presents to the emergency department with acute substernal chest pain that began a few hours ago. The pain is described as a “pressure” that radiates to his left arm. His past medical history is significant for hypertension and hyperlipidemia. He is on chlorthalidone for his hypertension and simvastatin for hyperlipidemia. He has a 30 pack-year history of smoking and drinks 1-2 beers on weekends. His EKG shows ST depressions in the anterior precordial leads and he is given the proper medications and sent for emergency revascularization. Seven days later, he develops dyspnea that worsens in the supine position. Bibasilar crackles are heard on pulmonary auscultation. Cardiac exam reveals a new 3/6 holosystolic murmur best heard at the apex with radiation to midsternum. What is the most likely etiology of this patient’s new symptoms?
Tested Concept

QID: 108576
1

Aortic stenosis

7%

(9/127)

2

Ventricular wall aneurysm

9%

(12/127)

3

Restrictive pericarditis

10%

(13/127)

4

Papillary muscle rupture

69%

(87/127)

5

Arrhythmia

2%

(2/127)

M 2 C

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(M1.CV.15.75) A 76-year-old male with a history of diabetes, hypertension, and CAD presents to the emergency department with shortness of breath and altered mental status. On physical exam, his BP is 85/40 mmHg and a V/VI crescendo-decrescendo systolic ejection murmur is heard that is immediately preceded by a click. Concerned about a cardiac pathology, the emergency medicine physician immediately obtains an EKG. Reading the EKG, she states that the EKG reading in combination with the cause of his murmur was most likely causing his current presentation. Which figure most likely represents the EKG of this patient? Tested Concept

QID: 106829
FIGURES:
1

Figure A

10%

(17/168)

2

Figure B

11%

(18/168)

3

Figure C

30%

(51/168)

4

Figure D

23%

(39/168)

5

Figure E

21%

(36/168)

M 2 A

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(M1.CV.14.208) A 68-year-old male visits his primary care physician after an episode of syncope during a tennis match. He reports exertional dyspnea with mild substernal chest pain. On physical exam a systolic crescendo-decrescendo murmur is heard best at the right 2nd intercostal space. This murmur was not heard at the patient's last appointment six months ago. Which of the following would most support a diagnosis of aortic stenosis? Tested Concept

QID: 100724
1

Presence of S3

6%

(2/35)

2

Murmur radiates to carotid arteries bilaterally

54%

(19/35)

3

Murmur radiates to axilla

9%

(3/35)

4

Asymmetric ventricular hypertrophy

23%

(8/35)

5

Double pulsation of the carotid pulse

9%

(3/35)

M 2 C

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(M1.CV.13.10) A 50-year-old female presents with a holosystolic murmur heard best over the apex, radiating to the axilla. She has no signs of pulmonary hypertension or edema. What best explains her lack of symptoms? Tested Concept

QID: 100526
1

The right ventricle is compensating with decreased compliance

0%

(0/35)

2

The left atrium is compensating with increased compliance

51%

(18/35)

3

The aorta is compensating with increased compliance

9%

(3/35)

4

As long as preload in the left ventricle is maintained there would be no symptoms

31%

(11/35)

5

There is only a ballooning of the valve which would not result in any hemodynamic changes in the heart

6%

(2/35)

M 4 E

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(M1.CV.13.147) A 37-year-old male presents to your clinic with shortness of breath and lower extremity edema. He was born in Southeast Asia and emigrated to America ten years prior. Examination demonstrates 2+ pitting edema to the level of his knees, ascites, and bibasilar crackles, as well as an opening snap followed by a mid-to-late diastolic murmur. The patient undergoes a right heart catheterization that demonstrates a pulmonary capillary wedge pressure (PCWP) of 24 mmHg. The patient is most likely to have which of the following? Tested Concept

QID: 100663
1

Increased pulmonary vascular compliance

17%

(8/48)

2

Decreased pulmonary artery systolic pressure (PASP)

4%

(2/48)

3

Increased left ventricular end diastolic pressure (LVEDP)

31%

(15/48)

4

Normal or decreased left ventricular end diastolic pressure (LVEDP)

40%

(19/48)

5

Decreased transmitral gradient

2%

(1/48)

M 2 E

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(M1.CV.13.31) A 27-year-old male with a history of injection drug use has been feeling short of breath and fatigued for the past several weeks. He is having trouble climbing the stairs to his apartment and occasionally feels like his heart is racing out of control. His past medical history is most notable for a previous bout of infective endocarditis after which he was lost to follow-up. On exam, you note that his carotid pulse has rapid rise and fall. Which of the following would you also expect to find? Tested Concept

QID: 100547
1

Mid-systolic click

32%

(9/28)

2

Fixed, split S2

0%

(0/28)

3

Venous hum

11%

(3/28)

4

Widened pulse pressure

43%

(12/28)

5

Systolic murmur that increases with valsalva

11%

(3/28)

M 2 E

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(M1.CV.13.97) A 58-year-old woman with a history of rheumatic fever has been experiencing exertional fatigue and dyspnea. She has begun using several pillows at night to sleep and occasionally wakes up at night gasping for air. On exam, she appears dyspneic and thin. Cardiac exam reveals a loud S1, opening snap, and apical diastolic rumble. Which of the following is the strongest predictor of the severity of her cardiac problem? Tested Concept

QID: 100613
1

Greater intensity of the diastolic rumble

16%

(5/31)

2

Short time between A2 and the opening snap

52%

(16/31)

3

Presence of a soft P2

0%

(0/31)

4

Shorter duration of the diastolic rumble

6%

(2/31)

5

Presence of rales

23%

(7/31)

M 2 B

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(M1.CV.12.5) A 60-year-old woman is found to have the following pressure vs. volume profile in her left ventricle during an analysis of her cardiac cycle. See Figure A for a comparison of her profile (in red) versus a normal profile (outlined in black). Which of the following is most likely to be appreciated on auscultation? Tested Concept

QID: 100521
FIGURES:
1

Crescendo-decrescendo systolic ejection murmur

17%

(5/29)

2

Holosystolic, harsh-sounding murmur

10%

(3/29)

3

Late systolic crescendo murmur

7%

(2/29)

4

Continuous machine-like murmur

3%

(1/29)

5

Holosystolic, high-pitched "blowing murmur"

59%

(17/29)

M 2 B

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Evidence (13)
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