Condition
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Aortic dissection
Acute, tearing chest pain radiating to the back, associated with hypertension, Marfan’s; can present with stroke, MI, tamponade, acute aortic insufficiency; CXR-wide mediastinum
Aortic regurgitation
Diastolic murmur loudest at the upper right sternal border, may occur with aortic dissection, may also occur in congenital diseases such as bicuspid aortic valve and Marfan’s syndrome
Aortic stenosis
Systolic crescendo-decrescendo murmur loudest at the upper right sternal border, weak and delayed peripheral pulses (parvus et tardus), poor prognostic indicators include angina, syncope, and CHF
Pulmonic stenosis
Systolic murmur that does not radiate into the neck, heard loudest along the left sternal border, murmur increases with inspiration, RV heave on palpation
Endocarditis
Classically found in IV drug users, but also look for a history of rheumatic valve disease or congenital anomalies; fever, new murmur, positive blood cultures, and echocardiographic evidence of vegetations on valves; new conduction abnormalities raise concern for intracardiac abscess
Cardiac arrhythmia
Diagnosed by ECG, stable patients may be treated with antiarrhythmics, unstable patients should be electrically shocked
Hypertrophic cardiomyopathy
Younger patients, sudden death in the family, brisk bifid carotid upstrokes, murmur does not radiate into the neck
Mitral regurgitation
Murmur is holosystolic and radiates to the axilla and not the carotids, carotid upstroke may be normal, patients with mitral valve prolapse are at increased risk, as are patients with a history of rheumatic valve disease
Acute pericarditis
One systolic rub and two diastolic rubs may present with diffuse ST segment elevation on ECG, and patients with h/o of MI weeks ago and patients with renal failure are at increased risk; can lead to tamponade
Unstable angina
Episodic chest pain of cardiac origin that is progressively increased in intensity or is brought about by decreasing amounts of physical exertion; this is a type of acute coronary syndrome (ACS)
Noncardiac causes of chest pain
Pulmonary (e.g., PE, pneumonia, pneumothorax), GI (e.g., esophageal spasm, GERD), biliary (e.g., gallstones), pancreatic (e.g., pancreatitis)
What Is the Most Likely Diagnosis?
Given the presence of a crescendo-decrescendo murmur loudest at the upper right sternal border and the history of a murmur, the patient likely has aortic stenosis. The concerning signs that portend a worse prognosis in this patient are chest pain (i.e., angina) and near syncope.
History and Physical Exam
What Is the Significance of an S4?
This extra heart sound is most frequently heard in patients that have left ventricular hypertrophy. Although it is common in patients with aortic stenosis, it can also be heard in patients with hypertensive heart disease and hypertrophic cardiomyopathy, as these conditions also cause left ventricular hypertrophy and decreased left ventricular distensibility.
What Other Valvar Disease Can Be Mistaken for Aortic Stenosis?
Pulmonic stenosis may present with a similar crescendo-decrescendo murmur at the upper regions of the sternum. Hypertrophic obstructive cardiomyopathy (HOCM) also creates a similar murmur. This may be differentiated from aortic stenosis by asking the patient to perform a Valsalva maneuver, which would increase the murmur in HOCM but decrease its intensity in aortic stenosis. The Valsalva maneuver is done by asking the patient to exhale with force against a closed airway/glottis.
Does the Intensity of the Murmur Correlate with the Severity of the Valvar Disease? What About the Duration?
As the degree of valvar stenosis increases, the murmur usually decreases in intensity and duration. It also occurs later in systole. However, with all murmurs and bruits, the intensity should not serve as a marker of severity of disease.
What Are the Three Classic Symptoms of Aortic Stenosis? And How Do the Presence of Those Symptoms Affect Prognosis?
The three classic symptoms of aortic stenosis are angina, syncope, and congestive heart failure (CHF). These three symptoms are associated with a 50 % mortality rate at 5, 3, and 2 years, respectively.
Watch Out
The most concerning symptom in patients with aortic stenosis is dyspnea, since half of these patients with evidence of CHF will succumb to the disease within 2 years without surgical valve replacement.
What Are the Differentiating Features of the Various Cardiac Murmurs?
Murmur | Description | Location |
|---|---|---|
Aortic stenosis | Midsystolic crescendo-decrescendo | Upper right sternal border |
Aortic regurgitation | Decrescendo diastolic murmur | Lower left sternal border |
Mitral stenosis | Diastolic opening snap, low-pitched diastolic murmur, as stenosis worsens, the opening snap occurs later in diastole | Apex |
Mitral regurgitation | Holosystolic murmur, decreased or absent S1 | Apex, radiating to axilla |
Mitral valve prolapse (MVP) | Mid-/late systolic click, possibly followed by late systolic crescendo-decrescendo murmur | Apex |
Hypertrophic obstructive cardiomyopathy (HOCM) | Systolic crescendo-decrescendo murmur | Upper left sternal border |
What Changes Do You See in the Systolic Murmurs With Various Maneuvers?
Valsalva (decreases preload) | Handgrip (increases afterload) | Leg raise (increases preload) | |
|---|---|---|---|
Aortic stenosis | ↓ | ↓ | ↑ |
Hypertrophic cardiomyopathy | ↑ | ↓ | ↓ |
Mitral regurgitation | ↓ | ↑ | ↑ |
Ventricular septal defect | ↓ | ↑ | ↑ |
What Is Pulsus Alternans?
Pulsus alternans is physical exam finding wherein the amplitude of a peripheral pulse changes from beat to beat associated with changing systolic blood pressure. It is most commonly caused by left ventricular failure.
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