Valve diseases and murmurs

Question 1

Aortic stenosis - causes

Answer 1

1. Degenerative calcification (>65 y/o)
2. bicuspid aortic valve (<65 y/o)
3. Rheumatic heart disease
4. Williams syndrome (supravalvular)
5. HOCM (subvalvular)

Question 2

Aortic stenosis - presenation

Answer 2

SOB
FATIGUE
CHEST PAIN
SYNCOPE

Question 3

Aortic stenosis- signs

Answer 3

Harsh ejection systolic murmur 
Soft/absent S2 
S4 
Thrill 
Narrow pulse pressure 
slow rising pulse
LV hypertrophy

Question 4

Aortic stenosis - investigations

Answer 4

ECHO
CXR
ECG

Question 5

Aortic regurg - causes

Answer 5

Valve disease:

• Infective endocarditis
• Rheumatic fever
• RA/SLE
• bicuspid valve

Aortic root:

• Hypertension
• Aortic dissection
• Ehlers Danlos/ Marfans
• Ankylosing spondylitis

Question 6

Aortic regurg - symptoms

Answer 6

• mild= asymptomatic/few symptoms
• severe:
• SOB
• FATIGUE
• CHEST PAIN
• SYNCOPE
• PALPITATIONS
• PERIPHERAL OEDEMA

Question 7

Aortic regurg- signs

Answer 7

• Early diastolic murmur
• Collapsing pulse - water hammer pulse
• Wide pulse pressure- dynamic circulation
• De Musset’s sign- head bobbing
• Quincke’s sign- capillary pulsation on nailbed
• AUSTIN FLINT MURMUR- mid-late diastolic murmur (in severe aortic regurg)

Question 8

Aortic regurg- investigations

Answer 8

Echo
CXR
ECG

Question 9

Mitral regurg- Risk factors

Answer 9

• Female
• increasing age
• low body mass
• previous MI
• Renal failure
• Mitral valve prolapse/ mitral stenosis
• Ehlers Danlos / Marfans

Question 10

Mitral regurg- causes

Answer 10

1. Post MI- damage to papillary muscles or chordae tendineae
2. Infective endocarditis
3. Mitral valve prolapse
4. Rheumatic fever- valves inflammed
5. Congenital

Question 11

Mitral regurg - symptoms

Answer 11

• mainly asymptomatic
• If severe can develop signs of LV failure, pulmonary hypertension and arrhytmias:
• SOB
• Oedema
• fatigue

Question 12

Mitral regurg- signs

Answer 12

• Ejection systolic murmur
• Pansystolic + radiates to axilla
• Soft S1
• Widley split S2

Question 13

Mitral regurg- investigations

Answer 13

ECHO
CXR- cardiomegaly
ECG - broad p wave

Question 14

Mitral regurg- management

Answer 14

Acute mitral regurg: 
- Nitrates 
- Positive inotropes 
- Diuretics 
- Baloon valvuloplasty 
Surgery - repair > replacement in degenerative regurg if possible

Chronic heart failure:

• ACEi
• beta blockers
• Spiro

Question 15

Mitral stenosis- causes

Answer 15

RHEUMATIC FEVER!

others:

• mucopolysacharidoses
• Carcinoid and endocardial fibroelastosis

Question 16

Mitral stenosis - signs

Answer 16

• mid-Late diastolic murmur (best on expiration)
• Malar flush
• AF
• Low pulse volume
• Loud s1
• Opening snap closer to S2

Question 17

Mitral stenosis - investigations

Answer 17

CXR- LA enlargement

Echo- cross sectional area <1

Question 18

systolic murmurs?

Answer 18

1. Mitral regurg
2. Aortic stenosis
3. ASD
4. Pulmonary stenosis
5. HOCM
6. VSD
7. Tricuspid regurgitation
8. tet of fallot
9. Mitral valve prolapse
10. Coarctation of aorta

Question 19

Ejection systolic murmurs?

Answer 19

1. Aortic stenosis
2. ASD (louder on inspiration)
3. Pulmonary stenosis (louder on inspiration)
4. HOCM
5. Tet of Fallot

Question 20

Pansystolic/holosystolic murmurs?

Answer 20

1. Mitral regurg (blowing)
2. VSD - harsh ejection systolic
3. tricuspid regurg (louder on inspiration)

Question 21

Late systolic?

Answer 21

1. Mitral valve prolapse

2. coarctation of aorta

Question 22

Diastolic murmurs ?

Answer 22

1. Aortic regurg
2. Mitral stenosis
3. Austin- Flint
4. Graham steel

Question 23

Early diastolic murmurs?

Answer 23

1. Aortic regurg

2. Pulmonary regurg (Graham Steel murmur)

Question 24

Late diastolic murmurs?

Answer 24

1. Mitral stenosis (rumbling)

2. Austin Flint - severe aortic regurg (mid-late diastolic)

Question 25

Continuous machine gun murmur?

Answer 25

Patent Ductus Arteriosus