A 67-year-old man presents to
the ED with sudden onset of
chest pain and shortness of
breath. He is 5 days status-post
inferior wall myocardial
infarction. On examination the
patient has pulmonary edema
and a loud holosystolic murmur
heard best at the left lateral
sternal border, with adiation to
What is the most appropriate
-Gradual dyspnea on
exertion and fatigue
-Palpitations (AF )
-Abrupt dyspnea, tachypnea,
Cardiogenic shock, Chest pain
-Symptoms of (endocarditis, MI,
O/E holosystolic, at the apex
and radiating to the axilla
midsystolic murmur radiates to
the base not the axilla. +
Patients may deteriorate quickly due to
cardiogenic shock or cardiac arrest
left atrial and ventricular
Atrial fibrillation and P mitrale
- no atrial enlargment
- no LVH
minimally enlarged left atrium,
pulmonary edema, left ventricular
Normal cardiac silhouette,
■ Treat CHF & AF
■ Anticoagulate if
■ Valve replacement
■ pulmonary edema ttt.
■ Nitroprusside for afterload reduction
(increases forward output by increasing
aortic flow and partially restoring mitral
valve competence as left ventricular size
■ Dobutamine if hypotensive.
■ Intra-aortic balloon pump as bridge to
■ Immediate valve replacement.
■ Treat the underlying disease process.
– with acute episodes of respiratory distress
due to pulmonary edema and
asymptomatic in between attacks
– Pronounced dyspnea may mask angina
that accompanies the ischemia
– Aortic balloon counter pulsation
– Surgery may be warranted if mitral valve rupture
– Evaluate for endocarditis
– Treat atrial fibrillation with heparin, control ventricular
rate with beta blockers and calcium channel blockers
– Keep INR 2-3
• Common, specially
young thin females.
• autosomal dominantmainly
• association with anxiety dis.
Myxomatous proliferation of
leaflet → abnormal stretching
of valve leaflets during systole
asymptomatic, Atypical chest pain,
Palpitations, Lightheadedness, Dyspnea.
■ Early to midsystolic click with high-pitched
late systolic murmur best at left lateral
■ standing→ earlier and greater prolapse →
accentuates the click +moves it closer to S1
■ asymptomaticNo treatment.
■ Proph. endocarditis if regurgitation or
thickened valve leaflets.
■ β-Blockers may help with atypical
■ ECG: Nonspecific c ST-T wave
■ CXR: NAD
Tachydysrhythmias (atrial and ventricular)
PSVT (most common dysrhythmia)
Increased incidence of WPW, PACs, PVCs
Ventricular tachycardia (VT) possible
Sudden death ( Risk factors include syncope/pre-
syncope, inferolateral ST-T changes and thickened or
redundant valve leaflet on TTE).
A 72-year-old woman is brought to the ED
following a syncopal event.
She reports orthopnea and vague,
intermittent chest pain, both present for the
past 6 months.
o/e : BP of 108/84, rales at both lung bases,
a prolonged apical impulse, and a loud
systolic murmur radiating into her neck.
What test will confirm the most likely
What medication is important to avoid in
Angina + Syncope + Dyspnea(dCHF)
- >65 years, calcified valve degeneration.
- younger patients congenital bicuspid valve.
- Rheumatic heart disease (less common)
specially if mitral valve diseased.
■ LV outflow is obstructed → LVH, ↓ cardiac output,
and eventual dilated cardiomyopathy with
■ signs or symptoms if aortic outflow is ↓75% (to < 1
■ Narrowed pulse pressure
■ Heaving, prolonged apical impulse
■ Crescendo–decrescendo systolic to the neck
■ CHF symptoms
■ ECG: LVH with strain, left bundle branch block.
■ CXR: LVH, pulmonary congestion .
■ Echocardiography: Confirms & measures.
Angina + Syncope + Dyspnea(dCHF)
Exercise stress testing may provoke dysrhythmias and
■ Treat CHF with gentle diuresis.
■ Rule out ACS in acute presentations.
■ Hydrate gently for hypotension.
■ Preload or afterload reducers (no nitroglycerin)
■ Negative inotropes.
■ Prophylaxis for endocarditis.
■ Definitive treatment is valve replacement.
■ Sudden death from dysrhythmias or acute onset of failure may occur
■ Survival is 2–5 without replacement.
-Abrupt onset of dyspnea
-Chest pain ( if aortic dissection)
Gradual onset of dyspnea on exertion,
orthopnea, nocturnal dyspnea
- Tachycardia, tachypnea
- Pulmonary edema and
- High-pitched blowing diastolic
murmur heard best at left
- Normal pulse pressure
■ Widened pulse pressure (opposite of AS)
■ same diastolic murmur.
■ Austin Flint murmur (mid-diastolic rumble)
■ “Water hammer” pulse
■ Quincke’s sign
■ Duroziez’s murmur
■ De Musset sign
■ Congestive heart failure
- ECG : normal
- CXR: Pulmonary edema.
-ECG: LVH, left atrial enlargement.
- CXR: Congestive heart failure.
-Standard for pulmonary edema
- Nitroprusside for afterload reduction
- Dobutamine (in addition to
nitroprusside) if hypotensive
- Immediate valve replacement
- Antibiotics: If endocarditis suspected
- Avoid: Intra-aortic balloon pump
■ Nifedipine for asymptomatic AR
■ Afterload reducers, digoxin,
hydralazine, and surgical referral for
elective valve replacement for
■ Prophylaxis for endocarditis
CAUSES: right ventricular
dilation (pulmonary HTN),
endocarditis, and rheumatic
Dyspnea, Lower extremity
EXAM: Holosystolic murmur
at left lower sternal border
■ ECG: Right atrial and ventricular
enlargement, atrial fi brillation (in the majority
■ Echo is confirmatory.
■ Treat atrial fibrillation.
■ Endocarditis prophylaxis
●Valve obstruction due to thrombosis or
●Structural deterioration, particularly with
●Paravalvular regurgitation ( leak )
● abrupt mechanical valve failure
■ Vary with location and rapidity of valve
■ Findings of severe anemia (due to hemolysis)
■ Findings consistent with aortic/mitral
regurgitation (acute or chronic)
■ Muted mechanical valve sounds, if
mechanical valve failure
Percutaneous Aortic “Valve in Valve”
Implantation for Severe Aortic Regurgitation in
a Degenerated Bioprosthesis
ETIOLOGIES MURMUR PHYSICAL FINDINGS
Radiating → neck
Paradoxically split S2
Narrowed pulse pressure
Diminished and slow-rising carotid pulse
Blowing diastolic Heard best at
left sternal border
Acute > Pulmonary edema and CV collapse
Chronic > “Water hammer” pulse ,
Quincke’s sign, Duroziez’s murmur, De
MS Rheumatic heart Diastolic Heard best at apex Loud S1
Loud holosystolic Heard best at
apex Radiating → base
Acute : Pulmonary edema and CV collapse
Chronic: LV heave
Late systolic heard best at left
lateral heart border
Early to mid systolic click
■ In a patient with severe mitral stenosis, hypovolemia and tachycardia
are poorly tolerated. “Slow and full” are appropriate goals.
■ In patients with critical aortic stenosis, excessive preload reduction
with vasodilators and diuretics is to be avoided.
■ In patients with acute aortic insufficiency, classic physical findings
may be absent. Medical stabilization entails the cautious use of
vasodilators and diuretics. Intra-aortic balloon counter pulsation is
■ Complications of prosthetic heart valves range from structural failure
and thrombosis to systemic embolization, hemolysis, and
■ admission depends on severity of symptoms not presence of
murmur unless aortic stenosis and syncope is suspected.
■ Valvular heart Disease pt. at risk for recurrent cardiovascular event.