questions 13

Valvular Disease

Topic updated on 12/18/16 1:06pm

Snap Shot
  • A 57-year-old man presents to the emergency department complaining of severe chest pain and difficulty breathing. His exam reveals a weak, delayed carotid upstroke and a parodoxically-split S2.
  • The leading cause of valvular heart disease in the United States is 
    • mechanical degeneration
  • In the developing world
    • rheumatic fever is the most common etiology
Aortic Stenosis
  • Introduction
    • most often occurs in the elderly
    • mechanical wear and tear is the primary etiology resulting in dystrophic calcification   
    • can result from chronic rheumatic fever, though more often the mitral valve is damaged
    • pediatric patients usually have unicuspid or bicuspid defects
  • Symptoms/physical exam
    • asymptomatic until very advanced  
    • once symptomatic, patients progress rapidly (5 years)
      • angina with exercise due to ↓ coronary perfusion
      • syncope with exercise
      • concentric LV hypertrophy leading to CHF
    • chest auscultation reveals
      • parodoxically split S2 
        • aortic valve closes later than normal which results in a single sound during inhalation when P2 closes later and a split S2 during exhalation when P2 closes earlier
      • classic crescendo-decrescendo murmur
        • peaks in early systole
        • heard in the 2nd right intercostal space and radiates to the carotids
        • ↓ preload = ↓ murmur intensity (less blood passing through stenotic valve)
        • the later in systole the crescendo peaks → the more advanced the stenosis
    • other signs include
      • pulsus parvus et tardus
        • weak and late pulse due to the lost pressure traversing the stenotic valve
      • ejection velocity of blood is increased due to the same amount of blood needing to pass through a smaller valve area
        • speed is directly proportional to severity of valvular stenosis
Aortic Regurgitation
  • Introduction
    • may appear acutely or chronic
      • acute causes include trauma, aortic dissection, and infection
        • due to aortic root dilation
      • chronic cases include
        • birth defects
        • rheumatic fever
        • connective tissue disorders
        • longstanding essential hypertension
  • Symptoms/physical exam
    • patients may present with worsening symptoms including
      • dyspnea on exertion
      • orthostatic hypotension
    • chest auscultation reveals
      • blowing early diastolic murmur at LSB
        • due to blood rushing back into heart
      • Austin Flint murmur
        • retrograde blood from aortic valve during diastole hits the anterior leaflet of the mitral valve
    • other signs
      • head-bobbing with heart beats
        • due to wide pulse pressure
      • Corrigan's pulse: carotid pulse with rapid rise and fall 
      • water hammer pulse
      • femoral bruits on compression of femoral pulse 
Mitral Stenosis
  • Introduction
    • most common etiology continues to be chronic rheumatic fever
    • reduced blood flow through valve results in LA dilation
  • Symptoms/physical exam
    • presents with wide range of symptoms
      • dyspnea on exertion
      • arrhythmias
      • orthopnea
      • infective endocarditis
    • chest auscultation may reveal
      • opening snap
        • heard best at the apex
        • time between A2 and OS is inversely correlated with severity of MS  
      • followed by mid-diastolic rumble
        • due to turbulent blood passing with increased velocity through the stenotic valve
    • other signs include
      • crackles and rales indicative of pulmonary edema
        • due to congestion of blood behind the left heart
      • dilated atria may
        • alter conduction and result in atrial fibrillation
        • compress esophagus resulting in dysphagia for solids but not liquids
        • compress the left recurrent laryngeal nerve resulting in hoarsness
    • pressure is propagated proximally to the stenosis 
      • pulmonary capillary wedge pressure (PCWP) is elevated
      • Elevation in pressure is not seen past the stenosis
        • HOWEVER left ventricular end diastolic pressure is typically normal i.e., in mitral stenosis PCWP does NOT reflect LVEDP
        • The transmitral gradient is elevated 
Mitral Regurgitation
  • Introduction
    • major causes include
      • rheumatic fever
      • chordae tendonae rupture 
      • mitral valve prolapse
    • results in retrograde blood flow into left atria, leading to increased LV end-diastolic volume and increased left atrial volume
    • dilatation of the left atrium as well as dilation and hypertrophy of the left ventricle are late manifestations of chronic disease 
  • Symptoms/physical exam
    • presents with a range of symptoms including
      • dyspnea
      • orthopnea
      • fatigue
    • symptoms develop if regurgitation develops acutely or if the atria can no longer compensate in a chronic problem 
    • chest auscultation reveals
      • holosystolic murmur that radiates to the axilla  
Tricuspid regurgitation
  • Introduction
    • two major causes include
      • carcinoid heart disease
        • tumor of GI tract metastasizes to liver
          • note: must metastasize to liver because any hormones produced distal to the liver in the venous system would be metabolized by MAO in lungs
        • produces serotonin which fibroses the tricuspid and pulmonary valves
      • IV drug use
        • results in right heart endocarditis (S. aureus)
  • Symptoms/physical exam
    • pulsating liver
      • due to ↑ venous pressures behind the right heart
    • chest auscultation reveals
      • pansystolic murmur
        • ↑ intensity during inspiration due to ↑ venous return to right heart


Qbank (8 Questions)

(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? Topic Review Topic
FIGURES: A          

1. Crescendo-decrescendo systolic ejection murmur
2. Holosystolic, harsh-sounding murmur
3. Late systolic crescendo murmur
4. Continuous machine-like murmur
5. Holosystolic, high-pitched "blowing murmur"

(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? Topic Review Topic

1. The right ventricle is compensating with decreased compliance
2. The left atrium is compensating with increased compliance
3. The aorta is compensating with increased compliance
4. As long as preload in the left ventricle is maintained there would be no symptoms
5. There is only a ballooning of the valve which would not result in any hemodynamic changes in the heart

(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? Topic Review Topic

1. Mid-systolic click
2. Fixed, split S2
3. Venous hum
4. Widened pulse pressure
5. Systolic murmur that increases with valsalva

(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? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

(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? Topic Review Topic

1. Greater intensity of the diastolic rumble
2. Short time between A2 and the opening snap
3. Presence of a soft P2
4. Shorter duration of the diastolic rumble
5. Presence of rales

(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 a late diastolic blowing murmur best heard at the cardiac apex. The patient undergoes a right heart catheterization that demonstrates a pulmonary capillary wedge pressure (PCWP) of 24mmHg. The patient is most likely to have which of the following? Topic Review Topic

1. Increased pulmonary vascular compliance
2. Decreased pulmonary artery systolic pressure (PASP)
3. Increased left ventricular end diastolic pressure (LVEDP)
4. Normal or decreased left ventricular end diastolic pressure (LVEDP)
5. Decreased transmitral gradient

(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? Topic Review Topic

1. Presence of S3
2. Murmur radiates to carotid arteries bilaterally
3. Murmur radiates to axilla
4. Asymmetric ventricular hypertrophy
5. Double pulsation of the carotid pulse

(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?
Topic Review Topic

1. Aortic stenosis
2. Ventricular wall aneurysm
3. Restrictive pericarditis
4. Papillary muscle rupture
5. Arrhythmia

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