richard j gordon, md., facc evaluation of suspected valvular heart disease in the outpatient setting...
TRANSCRIPT
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Richard J Gordon, MD., FACC
Evaluation of Suspected Valvular Heart Disease in the Outpatient
Setting
No Financial Relationships to
Disclose
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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?
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ApproachHistory****Physical Exam****ElectrocardiogramChest x ray****ECHO****Stress testMRI/CT/Cardiac Catheterization
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HISTORY
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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)
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Physical Examination
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Physical ExamHeart SoundsPulses and pulse pressures,
differential, boundingCyanosis/clubbingHepatomegalyPalpable thrill***Murmur***
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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
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MurmursAortic Stenosis Mitral Regurgitation
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MurmurPathologic Innocent
Diastolic
Some systolic murmurs
High flow (younger pts, anemia, thyrotoxicosis)
Venous hums
Mammary souffles
Trivial or minimal systolic murmur
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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
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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)
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Holosystolic MurmurWide pressure gradient throughout
systole
Mitral regurgitation/Tricuspid Regurgitation
High pitched blowing, holosystolic heard best at apex, radiating to axilla
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Holosystolic MurmurMitral Insufficiency
Tricuspid Insufficiency
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Holosystolic Murmurs
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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
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MidsystolicAortic Stenosis Pulmonic Stenosis
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Early Systolic MurmurMuch less common and may be
difficult to hear
Acute MR
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Early Systolic Murmur
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Murmur
Chronic MR Acute MR
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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
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Late Systolic Murmur
MVP phonocardiogram
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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
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Early Diastolic Murmur
Acute AI AI
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Middiastolic murmurMismatch between diastolic flow and
valve sizeMitral stenosis/Tricuspid stenosisASDSevere,chronic AR( Austin Flint)Left lateral lying position
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Mid Diastolic MurmurMitral Stenosis
Mitral Stenosis
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PresystolicSound heard after atrial contraction
in diastole
Usually occur with mitral or tricuspid stenosis
Myxoma
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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
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Continuous Murmurs
Patent Ductus Arteriosus
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Benign systolic murmur
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Echocardiography2D3D Color flowDoppler (CW and PW)TDI
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EchocardiographyValve Morphology FunctionAssociated chamber sizesVentricular functionAssociated hypertrophyPulmonary vein and hepatic vein
flow Pulmonary pressures
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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
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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
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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
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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
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Class IIIGrade 2 or softer midsystolic
murmur (innocent murmurs)
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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
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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?
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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
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Should we get an echo? What’s the diagnosis?
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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?
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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
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Do you want to get an echo? What’s the diagnosis?
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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?
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Physical Exam120/80 pulse 60, regular
Normal Carotid upstroke
Regularly Rhythm Early Systolic ejection murmur heard at RUSB 2/6
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Electrocardiogram
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Do we need an echo?
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Questions?