Cardiovascular examination quiz Part 3

The first heart sound is usually loud in MS and is not considered as a sign of severity. More severe disease also has pulmonary hypertension, and atrial fibrillation is common in many cases of even mild-moderate disease. (link)

Rheumatic heart disease is by far the most common cause of MS in Australia. Congenital MS is rare, as is aortic regurgitation severe enough to impair mitral valve function and cause an Austin-Flint murmur. Calcific, degenerative disease affects the aortic valve, but not the mitral valve significantly. (link)

Other chronic causes include LVF, congenital endocardial cushion defects and radiotherapy. Acute causes are less common but include infective endocarditis, papillary muscle rupture and (very rarely) trauma. (link)

The sensitivity of clinical examination for at least moderate severity MR is approximately 65%. (link)

MVP (and papillary muscle dysfunction) usually has a normal first heart sound, whereas other causes usually cause a soft H1.
Both murmurs are loudest at the apex, but the murmur of MVP tends to be more late systolic than pansystolic (as for cardiomyopathy), and MVP more commonly radiates to the sternum or aortic area as the posterior leaflet of the MV is more commonly affected than the anterior one. MVP may also have a mid systolic click. (link)

There is a prominent v wave in the JVP in TR, not a prominent a wave (as might be expected in TS). Other features such as a pulsatile liver, ascites and prominent peripheral oedema are also suggestive of TR. (link)

TR is caused by tricuspid annular dilation in 75% of cases. This can be due to left or right ventricular failure or pulmonary hypertension.
Other causes include infective endocarditis (especially IV drug users), rheumatic heart disease (usually associated with mitral valve disease), Epstein’s anomaly, papillary muscle dysfunction, transvenous pacemaker insertion and trauma (rarely). It is commonly physiological with 75% of normal people having trivial – mild TR on echocardiography, however this is not clinically significant. (link)

Clinical examination for at least moderate TR is approximately 50%. (link)

TS is very rare, and nearly always rheumatic in origin with the aortic and mitral valves also involved. The JVP typically shows a slow y descent and a prominent a wave (if still in sinus rhythm). The diastolic murmur is similar to MS but louder on inspiration. There may be a pre-systolic pulsation of the liver. (link)

Pulmonary stenosis is uncommon, and is congenital in the vast majority of cases in children, often associated with other congenital abnormalities. In adult, carcinoid syndrome is a cause. The clinical features include peripheral cyanosis, a reduced pulse pressure , giant a waves in elevated JVP, a right ventricular heave / pulmonary thrill , an ejection click then ejection systolic murmur greatest in inspiration, H4 and pre-systolic hepatic pulsation. An ejection click can also occur in congenital forms of aortic stenosis, so is the least helpful of the features listed in differentiating PS from AS.(link)

The presence of a 3rd heart sound is the least useful differentiating feature as it can be present in either MR or a VSD. The murmur of a VSD is louder on inspiration and loudest at the left sternal border (or apex) whereas the murmur of MR is loudest at the apex and unchanged (or reduced) by inspiration. A VSD does not usually cause pulmonary oedema, whereas MR commonly does (right sided > L due to the direction of the regurgitant jet). (link)

Approximately 95% of soft murmurs in patients < 50 years of age are benign. Approximately 65% of murrmurs in asymptomatic ED patients are benign. (link)

Murmurs are present in nearly all women during pregnancy. They are usually soft, mid systolic, are heard along the left sternal border and increase in intensity during pregnancy. Pregnant women may also have continuous murmurs from cervical venous hums or increased mammary blood flow.(link)

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