VHD and murmurs

Question 1

Describe when the 4th heart sound may occur

Answer 1

Associated with HTN – stiff non-compliant LV from hypertrophy (HFpEF), requires more forceful atrial “kick” for adequate filling of LV generating the 4th heart sound
AS, HCM, & ischemic CAD (all leading to HFpEF)

Question 2

Describe the fourth heart sound (S4)

Answer 2

1) “Atrial gallop”
2) Late diastole just prior to S1
3) Low frequency – bell at apex with patient in left latera position
4) When palpable double impulse at cardiac apex = stiff non-compliant left ventricle
-> age 50 y/o, if S4 is also palpable = abnormal = HFpEF
-Confirm and Dx with echocardiogram

Question 3

Describe the Third Heart Sound (S3)

Answer 3

May signal early HF
Early diastole
Low pitched, bell @ apex with patient in left lateral position
Sound originate in ventricular wall as rapid expansion is abruptly halted from HF
Ventricular gallop

Question 4

List and describe the 3 states in which S3 may occur

Answer 4

1) Young healthy patient = physiology variant
2) HF due to LV dysfunction (dilated cardiomyopathy, ischemic heart disease, end stage valvular heart disease)
S4 heard in patients > 40 y/o = HF
3) Volume overload states
MR or VSD

Question 5

Factors that increase the loudness of innocent murmurs include what?

Answer 5

Fever
Exercise
Anxiety
Anemia and pregnancy – high flow states

Question 6

Innocent murmurs:
1) Are they common?
2) What are they?

Answer 6

1) Most common murmur heard in general population – up to 80%
2) Turbulence across normal Aortic or Pulmonary valve
High frequent vibrations at tips of leaflets

Question 7

Describe innocent murmurs and when they’re heard

Answer 7

1) Diamond shaped and peak early in systole (AS peaks late)
2) Heard best 2nd right ICS if aortic valve, 2nd left ICS if due to pulmonic valve
3) Heard in absence of heart disease and carry no negative implications for the patient

Question 8

Give the 7 Ss of benign murmurs

Answer 8

1) Sensitive to position changes
2) Single sound (no clicks, gallops, abnormal splits)
3) Small area (no radiation)
4) Short duration (not holosystolic or continuous)
5) Soft (not loud)
6) Sweet (not harsh, blowing)
7) Systolic (not diastolic

Question 9

List and describe the grades of murmurs

Answer 9

Grade 1/6 – “not sure I hear it” (or I am thinking about trail running)
Grade 2/6 – can be heard readily (even me)
Grade 3/6 – loud and easily heard
Grade 4/6 – can hear it and feel it (Thrill)
Grade 5/6 – audible with edge of stethoscope
Grade 6/6 – can hear it with stethoscope off chest wall

Question 10

What murmurs req. further evaluation?

Answer 10

1) Any diastolic murmur
2) Any new murmur in adults
3) Any murmur grade 3 or more
4) Any late systolic murmur (AS vs innocent murmur vs. MVP)
5) Any murmur that falls into diagnostic concern
-Hypertrophic Cardiomyopathy – increased murmur with standing
-AS – increased murmur with squatting

Question 11

What is the most common VHD? What’s its most common etiology?

Answer 11

MR is most common VHD, followed by AS and AR
Degenerative disease is most common etiology

Question 12

What type of regurg or stensosis is uncommon in the US today?

Answer 12

MS, most often caused by RHD

Question 13

GDMT recommends what for VHD?

Answer 13

Interval follow up echo And medical mgt.

Question 14

What is needed in order to initiate early intervention prior to or as symptoms develop (improves outcomes)?

Answer 14

Monitoring in asymptomatic patients with VHD (especially regurgitant valvular lesions)

Question 15

1) Stenotic lesions obstruct __________ flow
2) Regurgitation permits ____________ flow

Answer 15

1) forward
2) backward

Question 16

Acquired/Symptomatic VHD increases with what?

Answer 16

age

Question 17

VHD risk factors: Describe HTN

Answer 17

Associated with aortic dilation and AR
Present in ~ 50% patients dx with AS and MR
Increased afterload can worsen AR and MR

Question 18

VHD risk factors: Describe IE

Answer 18

Uncommon cause of valvular regurgitation but high mortality when present
Incidence higher in older patients and subpopulation…IV drug use

Question 19

VHD risk factors: Describe RHD (rheumatic heart disease)

Answer 19

Global importance, rare in USA
Delayed autoimmune response to GABHS infection

Question 20

VHD risk factors: Describe SLE

Answer 20

Most common cardiac manifestation is VHD
Liebman-Sacks vegetations – small inflammatory lesions most often on leaflet margins, most often Mitral Valve and Aortic valve
Usually only minimal clinical regurgitation
Associated with Embolic stroke

Question 21

VHD risk factors: Describe Primary antiphospholipid syndrome

Answer 21

Systemic arterial and venous thrombosis
Thrombi can develop on Mitral valves – pose substantial embolic risk

Question 22

Describe the etiologies of VHDs

Answer 22

1) Degenerative disease most common etiology
~ 50% of AS, AR, and MR
2) MS – RHD
3) Inflammatory, ischemic, congenital, and infectious contribute to VHD

Question 23

Describe the Dx of VHDs

Answer 23

1) History significant
Management of VHD depends on development of LV dysfunction and SYMPTOMS (cardiomyopathy)
2) PE - focused
Should focus on detection of murmurs and extra heart sounds via auscultation
Changes in preexisting murmurs or heart sounds

Question 24

Give 3 examples of left sided systolic murmurs

Answer 24

Aortic stenosis
Mitral regurgitation
Mitral valve prolapse

Question 25

Give 2 examples of right sided systolic murmurs

Answer 25

Pulmonary stenosis and tricuspid regurgitation

Question 26

Aortic stenosis (AS): What is it?

Answer 26

Forward flow systolic murmur Often accompanied by aortic regurgitation

Question 27

Aortic stenosis (AS): What are the etiologies?

Answer 27

1) Young adults - Congenital bicuspid valve resulting in early calcification/degeneration of AV 2) Elderly – age related calcification/degenerative of tricuspid AV 3) Rheumatic disease 4) Infective endocarditis

Question 28

Describe the pathogenesis of AS

Answer 28

Calcified AV LV outflow obstruction of AV (not same as subaortic valve LV outflow obstruction due to HoCM) LVH LV HF

Question 29

Describe the presentation of AS

Answer 29

1) Insidious onset 2) Triad: -Exertional syncope (stairs, shoveling snow, etc.) -Dyspnea -Angina

Question 30

Describe what you'll see with AS on PE

Answer 30

1) Severe AS - may palpate a thrill and sustained apex beat/heave 2) Severe AS - delayed and/or diminished carotid upstroke, decreased pulse pressure 3) Systolic murmur -right 2nd ICS -Harsh crescendo-decrescendo systolic ejection murmur

Question 31

Describe the murmur heard in AS in detail

Answer 31

1) Sensitive to position change – pre-load dependent 2) Ejection click (extra sound), associated with spit S2 and S4 gallop 3) RUSB 2nd ICS with radiation to carotids (neck) and apex (not small) -Heard best sitting, leaning forward, exhalation 4) Crescendo – decrescendo (long duration) 5) Loud (not soft), +/- thrill 6) Harsh, blowing (not sweet) 7) Systolic

Question 32

1) In what conditions does an increase in pre-load increase a forward flow murmur? 2) Does a decrease pre-load decrease forward flow murmur?

Answer 32

1) AS, MR (except HoCM) 2) Yes, except HoCM

Question 33

What are the extra sounds in AS?

Answer 33

Ejection click due to calcified leaflets Split S2 – delayed opening and ejection of blood through AS S4 – due to LVH – stiffer, less compliant LV wall

Question 34

List the diagnostic tests for AS

Answer 34

CXR: normal ….. cardiomegaly, calcified aortic valve, prominent ascending aorta EKG: normal …. LVH (review criteria) Definitive diagnosis/monitoring: TTE Calcified AV, dilated aortic valve root, LVH Can non-invasively assess severity – see next slides Cardiac Left heart catheter - rarely used unless planning surgery

Question 35

List and describe the 3 parts of AS echocardiogram staging

Answer 35

1) Valve hemodynamics Jet velocity m/sec – increases with severity Mean gradient across the valve - increases with severity 2) Valve anatomic changes Valve opening (cm-squared) – increased stenosis = increased severity 3) Hemodynamic affects on LV LVH … resulting in HF

Question 36

How fast does AS progress once symptomatic?

Answer 36

rapid progression – 50% mortality @ 2 years if untreated

Question 37

Stages A-D of VHD are based on what 4 things? (according to the ACC guidelines)

Answer 37

1) Risk factors 2) Response of the ventricle and pulmonary circulation 3) Valve hemodynamics 4) Symptoms

Question 38

When may earlier VHD intervention be considered?

Answer 38

If indicated by results of exercise testing, biomarkers, rapid progression, or the presence of very severe stenosis.

Question 39

Describe Echocardiogram monitoring per stage of AS

Answer 39

Once symptomatic (Stage D) or evidence of LV HFrEF (stage C2) = referral to cardiology for further testing and CT surgery intervention is appropriate

Question 40

Describe when bioprosthetic valves are appropriate

Answer 40

1) Bioprosthetic valves are recommended for patients of all ages who are unable to undergo long-term anticoagulation – i.e., less thrombogenic 2) Preferred for older patients to minimize risk of bleeding and need for anticoagulation

Question 41

Describe when mechanical valves are appropriate

Answer 41

are generally preferred for younger patients (<60 y/o) due to greater longevity and reduce need for repeat surgery… but more thrombogenic Need lifelong anticoagulation

Question 42

What makes up the mitral valve apparatus? (any part of this apparatus can be affected with MR)

Answer 42

1) Leaflets 2) Annulus 3) Chordae tendineae 4) Papillary muscle 5) Adjacent myocardium

Question 43

MR: What are 3 causes? What are 3 signs?

Answer 43

1) MI resulting in papillary muscle rupture 2) Infective endocarditis 3) Trauma 1) Acute increase in Left atrial pressure 2) New acute harsh systolic murmur 3) Acute Pulmonary Hypertension with pulmonary edema

Question 44

List some causes of chronic MR

Answer 44

-MVP -Rheumatic fever -Cardiomyopathy (HCM) -Congenital -Radiation (XRT) for cancer

Question 45

List the Sx of mitral regurg

Answer 45

Fatigue DOE Orthopnea Palpitations

Question 46

Describe the murmur heard with MR

Answer 46

Holosystolic – blurs S1 – S2 (long duration) Loud, blowing, constant intensity (harsh) Heard best at apex, +/- thrill (4th ICS, MCL) May radiate to left axilla (if posterior jet) or left sternal edge (if anterior jet) and be mistaken for AS Accentuated with patient on left side Increased with hand grip and squatting (increased afterload or preload) Decreased with standing, valsalva, exercise

Question 47

Describe the diagnostic testing for MR including EKG and CXR

Answer 47

1) Diagnosed based on TTE -MR -Enlarged LV, LA -LV dilation due to volume overload 2) EKG may show A. fib if LAE 3) CXR may show prominent pulmonary vasculature

Question 48

How should you manage asymptomatic MR?

Answer 48

Manage medically: 1) HF – ACEi or ARB, diuretics to manage volume 2) OAC if A. fib

Question 49

How do you Tx symptomatic MR?

Answer 49

1) Based on symptoms & impaired LV function 2) Valve repair or replacement

Question 50

List the etiologies of mitral valve prolapse (MVP)

Answer 50

1) Ehler Danlos syndrome (inherited connective tissue d/o) 2) Marfan syndrome (FB1N gene mutation affecting fibrillin = connective tissue d/o) 3) Degradation of MV leaflets and chordae tendineae -Excessive mitral leaflet tissue -Prolapse of redundant tissue into LA during systole

Question 51

Describe the murmur of MVP

Answer 51

1) Symptomatic more commonly in females 15 - 30 y/o 2) Thin, lean patients 3) MVP syndrome is associated with panic attacks, palpitations, dizziness 4) Apical Mid-late systolic click, +/- Late systolic murmur @ apex if MR present -Increased risk for MR 5) Murmur increased standing and Valsalva, decreased with squatting -Decreased preload increases murmur, increase preload decreases like (HoCM)

Question 52

How is MVP managed?

Answer 52

1) Asymptomatic = no treatment 2) Symptomatic patients – B-blockers -If MR, severe, symptomatic - surgery

Question 53

AS vs MR: What does each increase?

Answer 53

1) AS: Effectively increases afterload to LV 2) MR: Effectively increases pre-load/volume overload to LV

Question 54

AS vs MR: Describe the murmur of AS and where it radiates

Answer 54

2nd ICS Harsh, late peaking (crescendo-decrescendo), systolic murmur May radiate to (right) carotids and apex

Question 55

AS vs MR: Describe the murmur of MR and where it radiates

Answer 55

Apex with patient on left side Holosystolic murmur May radiate left axilla or left sternum Constant intensity May hear apical S3 gallop = volume overload

Question 56

What is pulmonary stenosis? Describe

Answer 56

Usually due to congenital condition Increased resistance to RV outflow RV end diastolic pressure increases Limits pulmonary blood flow, RV enlargement

Question 57

What are the Sx of pulmonary stenosis?

Answer 57

Mild – asymptomatic Progression – DOE, early onset fatigue, angina, syncope

Question 58

What will you see on PE of pulmonic stenosis?

Answer 58

1) Crescendo-decrescendo systolic murmur @ left 2nd ICS -May radiate to left shoulder -Preload depended – decreased with inspiration -P2 delayed 2) May progress to RHF: JVD, hepatomegaly, ascites, edema

Question 59

Pulmonic stenosis: 1) What will you see on TTE/ EKG? 2) What is the Tx?

Answer 59

1) TTE/EKG – thickened leaflets, RAD, RVH, RAE 2) Percutaneous pulmonary ballon valvuloplasty, RHF with diuretics

Question 60

Define tricuspid regurgitation

Answer 60

1) Failure of closure during systole 2) Regurgitation into RA

Question 61

Carvallo sign may be seen with what?

Answer 61

Tricuspid regurg (Carvallo = blowing, holosystolic systolic murmur increased with inspiration)

Question 62

What are the Sx of tricuspid regurg?

Answer 62

1) Typically, asymptomatic 2) LV failure – decreased CO - fatigue and DOE 3) RV failure – volume overload - dependent edema, abdominal fullness

Question 63

What are the exam findings with tricuspid regurg?

Answer 63

1) Murmur – blowing, holosystolic systolic murmur increased with inspiration (referred to as Carvallo sign) and squatting, heard best over TV area 2) Findings of RHF 3) Markers of severity – high JVD, pulsatile liver, anasarca

Question 64

Tricuspid regurg: 1) How do you Dx? 2) How do you Tx?

Answer 64

1) Dx with TTE/EKG 2) Fix cause of TR, diuretics, valve surgery