Murmur | Aortic stenosis | Aortic Regurg | Mitral Stenosis | Mitral Regurg |
O/E | Slow-rising, low vol pulse Narrow pulse pressure Undisplaced, sustained (heaving) apex Ao thrill ESM to carotids Soft S2 |
Collapsing, large vol pulse Wide pulse pressure Displaced, hyperkinetic apex Ao thrill Early diastolic murmur (LLSE) (MDM aka Austin Flint)) Mid-systolic flow Quincke's (nail bed)
Traube's (pistol-shot femoral) Duroziez (diastolic murmur prox to fem arty compression) Corrigan's (neck) De Musset's (nodding) Muller (uvula)
| Malar flush Small vol pulse +/-AF Undisplaced, tapping apex RV heave Loud S1 (mobile valve only) OS (after S2 mobile valve only) Mid-diastolic murmur (apex)
Pre-systolic accentuation (if in SR) | Small vol pulse +/-AF Displaced thrusting apex Apex thrill RV heave Soft S1 Split S2 (early closure of AoV) Loud P2 (PHT) PSM " axilla S3
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Severity | Absent/soft A2 Delayed A2 Delayed ESM Narrow pulse pressure Slow-rising pulse Thrill/heave LVF S4 | Loud, short EDM Soft S2 S3 Wide pulse pressure LVF Austin Flint Hill's sign (SBP legs > arms) | Longer MDM OS nearer A2 PHT | Displaced apex (? size LV) Signs of LVF
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Complications | LVF IE Conduction dis | | PHT IE Pulmonary oedema CVA (thromboembolic) Haemoptysis/hoarseness | IE Pulmonary oedema
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Causes | Congenital Degenerative (calcified) Bicuspid Rheumatic Assoc ?: Coarctation Bicuspid AV Angiodysplasia MAHA | Congen Acute Chronic Valv IE RhF CTD (inc RA) Ao root Trauma Dissect (A) Dilatation (HTN, marfan's) Aortitis (syphilis, ank spond) Acquired: | RhF (? f) Rarely [Congen SLE Lt atrial myxoma RA Carcinoid] | Congen (assoc ? secundum ASD) Acute: IE Acute MI Chronic: IHD (functional) RhF CTD MVP Valvotomy Amyloid HCM
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ECG | LVH, LBBB, LAD | LVH, TWI | P-mitrale, AF, RVH | P-mitrale, AF, LVH
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CXR | Normal +/- calcified valve | Cardiomeg, wide mediastinum | Large LA, calcified valve | Cardiomeg, pulm oedema
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Echo | Valve area <0.5 cm2 | LVESD >55mm | Valve <1cm2/m2 | LVEF <55%
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Mx | Asymptomatic: None, unless gradient >50mmHg or worsening ECG (6/12 review, ppx Abx) Symptoms: ARV +/-CABG (operate prior to LV dysfunction) B-blockers (increase ejection time) | Acute: AVR Chronic: Sx (prior to LV dysfunction) Or, when pulse pressure >100, ECG changes & LV enlarged on CXR (65% @ 3 yrs) | Medical: Warfarin, Digoxin (rate control crucial), diuretics (reduced preload), ppx Abx Surgery: Valvuloplasty (pliable non-calcified valve ? minimal regurg & no Lt atrial thrombus) Valvotomy (open/closed) MVR | Medical: Diuretics, ACE, Warfarin, ppx Abx Surgery: MV repair (ideally) or MVR (when symptomatic, prior to LV dilatation)
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??dx | VSD HOCM PS MR Flow murmur | Mixed AoV Disease (AR/AS) Pulse: collapsing/slow-rising Apex: thrusting/heaving Thrill: absent/present SBP: high/low Pulse pressure: wide/narrow | Austin Flint Carey-Coombs (RhF) Lt atrial myxoma | TR VSD AS
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Anything else? | Listen for MS as tend to reduce signs of each other | Mixed MV Disease (MR/MS) Pulse: sharp, short/small vol Apex: thrusting/tapping S1: soft/loud S3: present/absent | Malar flush: MS, SLE, acne rosacea, dermatomyositis, carcinoid, erisipelas |
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