Updated: 3/8/2018

Valvular Disease

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Review Topic
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Questions
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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 
  • 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 (14)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M1.CV.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? Review Topic

QID: 100663
1

Increased pulmonary vascular compliance

24%

(7/29)

2

Decreased pulmonary artery systolic pressure (PASP)

7%

(2/29)

3

Increased left ventricular end diastolic pressure (LVEDP)

17%

(5/29)

4

Normal or decreased left ventricular end diastolic pressure (LVEDP)

41%

(12/29)

5

Decreased transmitral gradient

3%

(1/29)

M1

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PREFERRED RESPONSE 4

(M1.CV.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? Review Topic

QID: 100521
FIGURES:
1

Crescendo-decrescendo systolic ejection murmur

27%

(3/11)

2

Holosystolic, harsh-sounding murmur

9%

(1/11)

3

Late systolic crescendo murmur

0%

(0/11)

4

Continuous machine-like murmur

0%

(0/11)

5

Holosystolic, high-pitched "blowing murmur"

64%

(7/11)

M1

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(M1.CV.4726) A 73-year-old man presented to the emergency department with acute substernal chest pain that began a few hours ago. The pain was described as a “pressure” that radiated 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 showed 2-mm ST elevations in the anterior precordial leads and he was given the proper medications and sent for emergency revascularization. Seven days later, he developed dyspnea that worsened in the supine position. Bibasilar crackles were heard on pulmonary auscultation. Cardiac exam revealed a new 3/6 holosystolic murmur best heard at the left sternal border. What is the most likely etiology of this patient’s new symptoms?
Review Topic

QID: 108576
1

Aortic stenosis

7%

(7/95)

2

Ventricular wall aneurysm

12%

(11/95)

3

Restrictive pericarditis

11%

(10/95)

4

Papillary muscle rupture

66%

(63/95)

5

Arrhythmia

1%

(1/95)

M1

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(M1.CV.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? Review Topic

QID: 100547
1

Mid-systolic click

22%

(2/9)

2

Fixed, split S2

0%

(0/9)

3

Venous hum

11%

(1/9)

4

Widened pulse pressure

44%

(4/9)

5

Systolic murmur that increases with valsalva

11%

(1/9)

M1

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PREFERRED RESPONSE 4

(M1.CV.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? Review Topic

QID: 106829
FIGURES:
1

Figure A

13%

(14/108)

2

Figure B

13%

(14/108)

3

Figure C

24%

(26/108)

4

Figure D

20%

(22/108)

5

Figure E

25%

(27/108)

M1

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(M1.CV.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? Review Topic

QID: 100724
1

Presence of S3

0%

(0/8)

2

Murmur radiates to carotid arteries bilaterally

75%

(6/8)

3

Murmur radiates to axilla

0%

(0/8)

4

Asymmetric ventricular hypertrophy

12%

(1/8)

5

Double pulsation of the carotid pulse

12%

(1/8)

M1

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PREFERRED RESPONSE 2
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(M1.CV.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? Review Topic

QID: 100526
1

The right ventricle is compensating with decreased compliance

0%

(0/12)

2

The left atrium is compensating with increased compliance

75%

(9/12)

3

The aorta is compensating with increased compliance

8%

(1/12)

4

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

17%

(2/12)

5

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

0%

(0/12)

M1

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(M1.CV.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? Review Topic

QID: 100613
1

Greater intensity of the diastolic rumble

25%

(2/8)

2

Short time between A2 and the opening snap

62%

(5/8)

3

Presence of a soft P2

0%

(0/8)

4

Shorter duration of the diastolic rumble

12%

(1/8)

5

Presence of rales

0%

(0/8)

M1

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