Carotid Impulse 

Aortic stenosis 

Angina (5 year life expec)

Syncope w/exertion (3 year life expec)

Congestive HF (2 year life expec)

• TOC = Echo 2D/Color Doppler 

Other Tests

• ECG - LVH and LAE 
• Cardiac cath - helpful/confirmatory; NEEDED if pts is older to look at the coronaries 

**Treatment is for symptoms, NOT the actual cause**

• So you are only going to treat aortic stenosis if is symptomatic or you have decreased LV fucntion 
• Can also use aortic valve replacement (biorosthetic or mechanical) 

Abnormal leaflets:

• Rheumatic fever 
• Endocarditis 
• Bicuspid or degenerative valve

Aortic annulus dilitation:

• Aortic aneurysm 
• Aortic dissection
• Inflammation (syphillis, Giant cell arteritis, Vascular disease ankylosis, spondylitits, Reiters)
• Marfan
• Osteogenesis imperfecta 

• Widended pulse pressure: This is going to cause a decreased diastolic pressure
• Imbalance b/t myocardial supply and demand:  B/c of the decreased diastolic pressure, you have decreased perfusion of the heart
• Increased LV size:  B/c increased SV b/c regurgitation and this is going to cause increased stress on the wall of the heart = further increase in demand 
• Pulmonary venous congestion: Acute = lots of increased pressure in the ventricle causes LV and LA to expand; chronic = less increased pressure b/c expanded and this actually worsens mitral valve regurg and causes pulmonary venous congestion. 

• Exertional dyspnea:  B/c increased contraction of the heart and causes more backflow and causes pulmonary venous congestion 
• Fatigue:  B/c you are have regurg you have less CO 
• Diminished exercise tolerance:  B/c regurg you have less CO 

Aortic regurgitation 

Called "Austin Flint murmur"

• Diastolic decrescendo blowing murmur
• S4 that progresses to an S3 w/advancement 
• Bounding pulses 
• Apical rumble "austin flint murmur" (caused by regurg blood hitting the anterior mitral valve leaflet)
• Hyperdynamic LV apical impulse 

Aortic regurgitation TOC

Other choices 

• Echo:  TOC 
• ECG:  LAE and LVH 
• Cardiac cath:  Helpful for confirmation and needed if pt is older to look for coronaries 

• Asymptomatic:  No good medical treatment, treat risk factors such as endocarditis or causitive agents
• Symptomatic:  Aortic valve replacement (bioprosthetic vs mechanical) 
• Treatment of symptomatic/severe aortic regurgitation in non-surgical candidate: Palliative; Vasodilators such as ACE-I or nifedipine 

Alterations of leaflets/commissures/annulus:

• Rheumatic fever 
• MVP
• Endocarditis 

Papillary muscle dysfucntion:

• Ischemic MI***
• Myocarditits***
• Dilated cardiomyopathy***

Alterations of LV or LA size and function:

• HCM
• LV enlargement 
• LA enlargement 

Eccentric hypertrophy:

• The heart is goiing to have an increased "preload" b/c of the mitral regurg and also an increased "afterload" b/c of the increased dilation due to the regurg
• Ths is going to cause an increase in the total stroke volume + an increase in forward stroke volume + LVESV is going to return to normal

Depressed contractility:

• Decreased SV b/c of decreased contractility 
• Causes increased LVEDV b/c the heart cannot squeeze all of the volume from the previous stroke out

***This decompensation is goiing to cause further dilation and further increase mitral regurgitation***

• Fatigue
• Dyspnea 
• Orthopnea 
• Left and/or right sided HR
• MVP syndrome 

**This is often obscured by the murmur**

Mitral regurg

Atrial septal defect 

• Holosystolic apical blowing murmur 
• Laterally displaced apical impulse 
• Split S2 (obsscured by murmur) 
• S3 gallop 

TOC for Mitral Regurg 

ECG findings 

• TOC:  Echno 2D Doppler
• ECG:  LAE; LVH 
• Cardiac cath:  Helpful/confirmatory, needed if pt. is older for looking at the coronaries 

• Chest pain 
• Palpitations 

• Mid-systolic click
• Late systolic murmur if it is associated with mitral regurg 

-It is often benign unless you have a rare complication

-Rare complications:

• Endocarditis 
• Progressive mitral regurg (acute and chronic)
• Thromboembolism 
• Atrial + ventricular arrhythmia 

• DOC:  Echo 2D/Color to directly visualize prolapse + presence and degreee of MR 

• Beta-blockers:  B/c of the hyper-adrenergic symptoms and to stop palpitations 
• Aspirin:  TIA w/o etiology 
• SBE prophylaxis: ONLY if there is a history of endocarditits or vavle replacement 

What about diurectic and an ACE for vasodilation?

• Rheumatic fever 
• Mitral annular Ca+ (needs to be MASSIVE but that is rare)
• Congenital (rare) 

• Normal mitral valve area = 4-6 cm^2
• Symptomatic = < 2cm^2
• Critical = < 1cm^2 

LA-Hypertension which leads to:

• Pulmonary interstitial edema
• Pulmonary hypertension (passive = obligatory b/c forward flow; reactive = protects interstitium from edema) → right sided heart failure
• LA stretch + atrial fibrillation: This can lead to increased HR which causes decreased LV filling; Decreased atrial "kick" which leads to decreased LV filling; Atrial thrombus formation

• Decreased ability to tolerate increased HR (decreased LV filling)
• Dyspnea (pulmonary venous congestion) 
• Fatigue (decreased CO)
• Inability to tolerate increased volume (b/c can't move it) 
• Hemoptysis 

Mitral stenosis 

Aortic stenosis?

• Loud S1
• Apical diastolic rumble (murmur) 
• Opening snap 
• Atrial fibrillation 
• May be associated with other murmurs: MR or AS; right sided murmurs; PI-Graham steel murmur; TR 

TOC for mitral stenosis

ECG findings 

• TOC:  Echo 2D/color doppler 
• ECG:  A-fib; LAE; RVH; RAE 
• Cardiac cath:  Helpful, confirmatory, needed if the pt is older to look for coronaries 

***Just like aortic stenosis, treatment is ONLY for symptoms***

• Diuretics: For pulmonary congestion 
• Ca/Beta-blockers/digoxin:  For A-fib 
• Anti-coagulation:  For A-fib 

***SBE Prophylaxis NOT recommended empirically***

• Surgical therapy treats the cause: 
• Percutaneous balloon valvuloplasty for a non-calcified pliable valve 
• Open commissurotomy- valve repair
• Mitral valve replacement 

• This is an autosmoal dominant transmission disease w/varable penetrance 
• Patient in this case is going to be between the ages of 12-20 and it is the leading cause of SCD in young athletes

Symptoms

• Chest pain 
• Dyspnea upon exertion
• Fatigue 
• Syncope 

• Harsh mid-systolic murmur at the LSB which may radiate slightly lateral 
• Normal carotid upstrokes 
• S4 
• Possible reverse splitting of S2 

***Classic sign of HOCM***

• Left-ventricle to aortic gradient increases while the aortic pulse pressure decreases after a pre-mature ventricular contraction (PVC)

Occurs in HOCM b/c increased contractility after a PVC beat increases the dynamic LVOT obstruction 

• Diastolic dysfucntion 
• Ischemic heart disease 
• Dynamic outflow tract obstruction 
• Mitral regurg + A. Fib

HOCM therapy

Asymptomatic and Symptomatic

• H/o cardiac arrest
• Sustained VT, FH of SCD
• LV thickness > 30 mm 
• Unexplained syncope 
• Abnormal exercise BP
• Holter monitor that reveals NSVT

• USUALLY it is secondary 

COPD,

Diseases leading to pulmonary HTN

Intracardiac shunts

• Priimary causes can be endocarditis, carcinoid syndrome, rheumatic fever, myxomatous degeneration, RV infarct, endomyocardial biopsy 

• These are going to be signs of Rx HF
• Edema
• Ascites
• Occasionally right upper quadrant pain

Murmur at the LSB which increases w/inspiration 

May radiate to the epigastrum 

• JVD 
• Large V-wave
• Hepatic enlargement
• Parasternal lift 
• Ascites 
• Edema
• Murmur at the LSM which increses w/inspiration
• Murmur may radiate to the epigastrum 

• Since most TR are 2ndary, then treat the cause
• Diuretics 
• Tricuspid repair (but rare) 

HOCM + Valsalva 

Increase or decrease murmur 

HOCM + Squat

Increase or decrease murmur

HOCM + Standing 

Increase or decrease murmur 

HOCM + Handgrip

Increase or decrease murmur

MR + Squat 

Increse or decrease murmur

MR + Stand 

Increase or decrease murmur?

MR + handgrip 

Increase or decrease murmur

Handgrip + HOCM

Ventricular volume 

Murmur intensity

LVOT Gradient 

Ventricular volume = increases

Murmur intensity = decrease 

LVOT Gradient = decrease

Valsalva + HOCM

Ventricular volume 

Murmur intensity 

LVOT Gradient 

Ventricular volume = decreases 

Murmur intesity = increased 

LVOT gradient = increased 

Amy Nitrite + HOCM

Ventricular volume 

Murmur intensity 

LVOT Gradient 

Ventricular volume = decreased

Murmur intensity = increased 

LVOT gradient = increased

Isoproterenol + HOCM 

Ventricular volume 

Murmur intensity 

LVOT gradient

Ventricular volume = decreased

Murmur intensity = increased 

LVOT gradient = increased 

Beta-blocker + HOCM 

Ventricular volume 

Murmur intensity 

LVOT Gradient 

Ventricular volume = increased 

Murmur intesnity = decreased 

LVOT gradient = decreased 

Phenylephrine + HOCM

Ventricular volume

Murmur intensity 

LVOT Gradient 

Ventricular volume = increased

Murmur intensity = decreased 

LVOT gradient = decreased