Mehl. Cardio: mitral reg/stenosis; MVP; Rheumatic heart disease 04-02 (2)

Question 1

M. Mitral regurgitation. what murmur?

Answer 1

Holosystolic (pan-systolic) or just regular “systolic,” 29 times out of 30

Question 2

M. Mitral regurgitation.
Q on NBME 20 offline for Step 1 has MR as “mid-systolic,” but I contend this is erratum.

Answer 2

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Question 3

M. Mitral regurgitation.
Most USMLE questions will not mention it radiating to the axilla.

Answer 3

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Question 4

M. Mitral regurgitation. Seen acutely in????

Answer 4

Rheumatic heart disease as a kid (valve scars over years later and becomes mitral stenosis).

Question 5

M. Mitral regurgitation. Can cause (venous) …?

Answer 5

Can cause JVD (i.e., back up all the way to the right heart); this is mentioned numerous times on the new NBMEs.

Question 6

M. Mitral stenosis. Murmur?

Answer 6

Described as “rumbling diastolic murmur with an opening snap”; can also be described as “decrescendo mid-late diastolic murmur” (i.e., following the opening snap).

Question 7

M. Mitral stenosis. What S sound?

Answer 7

Can cause a right-sided S4 if the pressure backs up all the way to the right heart (seen on NBMEs sometimes; this confuses students because they think S4 must be LV, but it’s not the case). An S4 is a diastolic sound heard in either the LV or RV when there is diastolic stiffening due to high afterload.

Question 8

M. Mitral stenosis. 99 proc cause?

Answer 8

99% of mitral stenoses are due to Hx of rheumatic heart disease (i.e., the patient had rheumatic fever as a child, where at the time it was mitral regurg, but years later it has now become mitral stenosis).

Question 9

M. MVP. Most common murmur.

Answer 9

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Question 10

M. MVP. what click?

Answer 10

Described as mid-systolic click.

Question 11

M. MVP. buzzy?

Answer 11

“Myxomatous degeneration” is buzzy term that refers to connective tissue degeneration causing MVP in Marfan and Ehlers-Danlos.

Question 12

M. MVP. in what pathologies??

Answer 12

MVP in Marfan and Ehlers-Danlos.

Question 13

M. MVP. symptoms?

Answer 13

almost always asymptomatic

Question 14

M. MVP. USMLE loves using MVP as a distractor in panic disorder questions, particularly on the 2CK Pysch CMS forms. They will give long paragraph about panic attack/disorder + also mention there’s a mid-systolic click; they’ll ask for cause of patient’s presentation -> answer = panic disorder, not MVP -> student is confused because they say mid-systolic click, but the MVP isn’t the cause of the patient’s presentation; the panic disorder is; MVP’s are usually incidental, benign, and asymptomatic.

Answer 14

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Question 15

M. Rheumatic heart disease. Mo? mechanism

Answer 15

Strep pyogenes (Group A Strep) oropharyngeal infection results in production of antibodies against S. pyogenes’ M-protein that cross-react with the mitral valve (i.e., molecular mimicry; type II hypersensitivity).

Question 16

M. Rheumatic heart disease.
Can occur with the aortic valve in theory, but on USMLE, it is always mitral valve.

Answer 16

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Question 17

M. Rheumatic heart disease. what valve always in usmle?

Answer 17

always mitral valve.

in theory - aortic valve

Question 18

M. Rheumatic heart disease. results in what valvular changes?

Answer 18

Results in mitral regurgitation acutely and mitral stenosis late, as discussed earlier

Question 19

M. Rheumatic heart disease. CP?

Answer 19

• Presents as JONES (J©NES) -> Joints (polyarthritis), © Carditis, subcutaneous Nodules, Erythema marginatum (annular, serpent-like rash), Sydenham chorea (autoimmune basal ganglia dysfunction that results in dance-like movements of the limbs).

Question 20

M. Rheumatic heart disease.
- Cutaneous Group A Strep infections don’t cause rheumatic fever, but can still cause PSGN.

Answer 20

.

Question 21

M. Rheumatic heart disease. Tx?

Answer 21

= penicillin.

Question 22

!!! M. Mitral regurgitation. ADULTS. Highest yield cause of MR on USMLE is????????

Answer 22

Highest yield cause of MR on USMLE is post-MI papillary muscle rupture. USMLE is obsessed with this. They’ll say hours to days after an MI, patient has new-onset systolic murmur. answer = MR.

Question 23

M. Mitral regurgitation. ADULTS. Can be caused by ….?2

Answer 23

Can be caused by general ischemia / dilated cardiomyopathy.

Question 24

M. Mitral regurgitation. ADULTS. Can cause JVD (i.e., back up all the way to the right heart); this is asked multiple times on the new NBMEs.

Answer 24

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Question 25

M. Mitral regurgitation. ADULTS. You do not do preoperative stress tests to determine perioperative MI risk if the patient has mere mitral regurg without other risk factors. For example, one of the 2CK forms gives a Q where smoker with MR has no shortness of breath or chest pain with exertion, and the answer is “no further management indicated,” where exercise stress test is wrong.

Answer 25

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Question 26

M. Mitral regurgitation. ADULTS. If the patient has Sx of heart failure or ischemia, then we do pre-op stress test to determine MI risk. I discuss stress tests later in this chapter.

Answer 26

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Question 27

M. Mitral regurgitation. ADULTS. When valve replacement?

Answer 27

The mitral valve is replaced if the patient develops severe pulmonary symptoms (i.e., shortness of breath / reduced exercise tolerance), reduced ejection fraction, arrhythmia, or endocarditis if valve function is destroyed.

Question 28

M. Mitral stenosis. ADULTS. Other HY presentation on USMLE is pregnant women with new-onset dyspnea in 2nd trimester and a diastolic murmur. This is because 50% increase in plasma volume by 2nd trimester causes the underlying subclinical MS to become symptomatic. Don’t confuse this with severe dyspnea and peripheral edema in late third-trimester, which is instead peripartum cardiomyopathy (antibody-mediated).

Answer 28

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Question 29

M. Mitral stenosis. ADULTS. The 1% of MS that’s not due to Hx of RF can be marantic (non-bacterial thrombotic endocarditis; NBTE)àendocarditis seen due to hypercoagulable state in the setting of malignancy, where the vegetations are small and verrucous, on both sides of the valve. This is in contrast to bacterial endocarditis, which causes large, floppy vegetations that lead to MR, not MS.

Answer 29

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Question 30

M. Mitral stenosis. ADULTS. Libman-Sacks endocarditis seen in SLE is due to antiphospholipid antibodies and is a type of NBTE.

Question 31

M. Mitral stenosis. ADULTS. First line Tx?

Answer 31

Balloon valvuloplasty is the 1st-line Tx for mitral stenosis. This is done if patient has minimal calcification of the valve + has pulmonary HTN.

Question 32

M. Mitral stenosis. ADULTS. When valve replacement?

Answer 32

Mitral valve replacement is done if balloon valvuloplasty fails, if patient has severe MS with dyspnea, arrhythmia, or calcification of the valve.

Question 33

M. MVP. does not progress to mitral regurg almost always. So don’t think that MVP and MR are the same.

Answer 33

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