Richard J Gordon, MD., FACC

Evaluation of Suspected Valvular Heart Disease in the Outpatient

Setting

No Financial Relationships to

Disclose

Case The patient is a 75 year old woman

who goes to see her PCP for a routine visit and is found on cardiac exam to have a murmur. The patient is relatively inactive and the most she does is walk around her house. She sometimes feels “weak” but does not report any obvious shortness of breath, angina, palpitations or syncope. She denies any significant PMH and no previous surgery. What to do next?

ApproachHistory****Physical Exam****ElectrocardiogramChest x ray****ECHO****Stress testMRI/CT/Cardiac Catheterization

HISTORY

History of Present Illness/Family HistoryMay or may not be helpfulClinical scenario helpful (IV drug

abuse, h/o rheumatic fever or MVP)

Shortness of breath, syncope, palpitations, angina

FH of congenital heart diseasePrevious procedures (i.e.,previous

valve replacement)

Physical Examination

Physical ExamHeart SoundsPulses and pulse pressures,

differential, boundingCyanosis/clubbingHepatomegalyPalpable thrill***Murmur***

Origin of MurmurForward flow through a narrowed

or irregular orifice into a dilated vessel or chamber (stenosis)

Backward flow through an incompetent valve(regurgitation)

High blood flow through a normal or abnormal valve

MurmursAortic Stenosis Mitral Regurgitation

MurmurPathologic Innocent

Diastolic

Some systolic murmurs

High flow (younger pts, anemia, thyrotoxicosis)

Venous hums

Mammary souffles

Trivial or minimal systolic murmur

Murmur

Systolic DiastolicPansystolic

(holosystolic)Systolic

ejection (midsystolic)

Early systolicMid to late

systolic murmurs

Continuous murmurs

Early high-pitched diastolic murmurs

Middiastolic murmurs

Presystolic murmurs

Continuous murmurs

8 Characteristics of Heart MurmurTiming in cardiac cycleIntensity (1 barely audible, 2 quiet but

obvious, 3 moderate, 4 loud, 5 louder heard with stethoscope barely off chest, 6 very loud heart without a stethoscope)

Location of maximal intensityShape (crescendo, decrescendo,

crescendo-decrescendo, plateau)Duration (pan-systolic, mid-systolic,etc)Radiation(axillary, carotids)Quality (blowing, musical, rumbling,

machinery)Pitch (high, medium or low)

Holosystolic MurmurWide pressure gradient throughout

systole

Mitral regurgitation/Tricuspid Regurgitation

High pitched blowing, holosystolic heard best at apex, radiating to axilla

Holosystolic MurmurMitral Insufficiency

Tricuspid Insufficiency

Holosystolic Murmurs

Midsystolic Usually crescendo-decrescendo murmurs

With increased ejection the murmur is louder, and subsides with relaxation

High flow rates with increased cardiac output

Harsh systolic, crescendo-decrescendo murmur heard right upper sternal border, radiates to carotids

MidsystolicAortic Stenosis Pulmonic Stenosis

Early Systolic MurmurMuch less common and may be

difficult to hear

Acute MR

Early Systolic Murmur

Murmur

Chronic MR Acute MR

Late Systolic MurmurSoft or moderately loud, high

pitched sounds at LV apexMalcoaptation of mitral leafletsMVP late systolic murmurs with a

clickAdvanced aortic stenosis with

decreased or absent S2 and often S4

Late Systolic Murmur

MVP phonocardiogram

Early Diastolic MurmurOccurs shortly after S2 when

intraventricular pressure drops below aortic or pulmonary pressures

Aortic regurgitation or pulmonary regurgitation

Decrescendo murmurs, soft and in early diastole, high pitched, often faint and blowing quality

Heard best at left upper sternal border when patient is seated forward and during expiration

Early Diastolic Murmur

Acute AI AI

Middiastolic murmurMismatch between diastolic flow and

valve sizeMitral stenosis/Tricuspid stenosisASDSevere,chronic AR( Austin Flint)Left lateral lying position

Mid Diastolic MurmurMitral Stenosis

Mitral Stenosis

PresystolicSound heard after atrial contraction

in diastole

Usually occur with mitral or tricuspid stenosis

Myxoma

Continuous MurmursOccur in of systole and persist the

into all are part of diastole High to low pressure gradients that

are present for end of systole and beginning of diastole

Persistent, Patent ductus arteriosisIntracardias Shunts

Continuous Murmurs

Patent Ductus Arteriosus

Benign systolic murmur

Echocardiography2D3D Color flowDoppler (CW and PW)TDI

EchocardiographyValve Morphology FunctionAssociated chamber sizesVentricular functionAssociated hypertrophyPulmonary vein and hepatic vein

flow Pulmonary pressures

Purpose of EchocardiographyIdentify the primary source of

murmurDefine pressure

gradients/hemodynamicsDetect secondary lesionsEstablish a reference for

comparisons Chamber size and functionIn association with exercise in select

cases

When Echo is probably not necessaryGrade 1 or 2 murmur in absence of

suspected endocarditisNormal systolic ejection patternNormal heart soundsNo suggestion of more severe heart

disease with provocative maneuvers

Echocardiography: IndicationsLevel 1CAsymptomatic patients with

diastolic murmurs, continuous murmurs, holosystolic,late systolic murmurs, murmurs associated with ejection clicks or murmurs that radiate to the neck or back

Murmurs with associated sxs or signs of heart disease

Asymptomatic with grade 3 or louder midpeaking systolic murmur

Class IIaUseful for evaluation of asymp pts

with murmur associated with other abnl cardiac physical findings (abnormal EKG or CXR)

Can be useful in patients whose signs/sxs are likely noncardiac in origin but cannot rule out cardiac basis

Class IIIGrade 2 or softer midsystolic

murmur (innocent murmurs)

National Center for Health Statistics 1999-2009The number of transthoracic

echoes have grown by 90 % and TEE by 70%

JACC Vol.60 SupplNo. 25, 2012

Case The patient is a 75 yo woman who

goes to see her PCP for a routine visit and is found on cardiac exam to have a murmur. The patient is relatively inactive and the most she does is walk around her house. She sometimes feels “weak” but does not report any obvious shortness of breath, angina, palpitations or syncope. She denies any significant PMH and no previous surgery. What to do next?

Physical ExamBP 140/80 pulse 75

Carotid Upstroke is delayed and weak (pulsus tardus)

Mid to late peaking murmur is heard at RUSB radiating to carotids. S1 normal, S2 absent, and S4 heard

Should we get an echo? What’s the diagnosis?

Case

The patient is a 75 yo woman who goes to see her PCP for a routine visit and is found on cardiac exam to have a murmur. The patient is relatively inactive and the most she does is walk around her house. She sometimes feels “weak” and does report shortness of breath. She denies any significant PMH and no previous surgery. What to do next?

Physical Exam Anxious and tachypnic

BP 170/100 120, irreg RR 25

Brisk, irregular, and sharp, but weak carotid upstroke

Lungs: Rales heard throughout lung fields

Cardiac: Irregularly, Irregular and rapid, high pitched , blowing holosystolic 3/6 systolic murmur heard best at the apex

Do you want to get an echo? What’s the diagnosis?

Case

The patient is a 75 yo woman who goes to see her PCP for a routine visit and is found on cardiac exam to have a murmur. The patient is relatively inactive and the most she does is walk around her house. She sometimes feels “weak” but does not report shortness of breath, angina, palpitations or syncope. She denies any significant PMH and no previous surgery. What to do next?

Physical Exam120/80 pulse 60, regular

Normal Carotid upstroke

Regularly Rhythm Early Systolic ejection murmur heard at RUSB 2/6

Electrocardiogram

Do we need an echo?

Questions?