2. Richard J Gordon, MD., FACC
Evaluation of Suspected Valvular Heart Disease in the Outpatient Setting
Richard J Gordon, MD., FACC
No Financial Relationships to Disclose

3. 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?

4. Approach History ****Physical Exam**** Electrocardiogram Chest x ray
****ECHO****
Stress test
MRI/CT/Cardiac Catheterization

5. HISTORY

6. History of Present Illness/Family History
May or may not be helpful
Clinical scenario helpful (IV drug abuse, h/o rheumatic fever or MVP)
Shortness of breath, syncope, palpitations, angina
FH of congenital heart disease
Previous procedures (i.e.,previous valve replacement)

7. Physical Examination

8. Physical Exam Heart Sounds
Pulses and pulse pressures, differential, bounding
Cyanosis/clubbing
Hepatomegaly
Palpable thrill
***Murmur***

9. Origin of Murmur
Forward 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

15. Murmurs
Aortic Stenosis
Mitral Regurgitation

16. Murmur Diastolic Some systolic murmurs
Pathologic
Innocent
Diastolic
Some systolic murmurs
High flow (younger pts, anemia, thyrotoxicosis)
Venous hums
Mammary souffles
Trivial or minimal systolic murmur

17. Murmur Early high-pitched diastolic murmurs Middiastolic murmurs
Systolic
Diastolic
Pansystolic (holosystolic)
Systolic ejection (midsystolic)
Early systolic
Mid to late systolic murmurs
Continuous murmurs
Early high-pitched diastolic murmurs
Middiastolic murmurs
Presystolic murmurs
Continuous murmurs

19. 8 Characteristics of Heart Murmur
Timing in cardiac cycle
Intensity (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 intensity
Shape (crescendo, decrescendo, crescendo- decrescendo, plateau)
Duration (pan-systolic, mid-systolic,etc)
Radiation(axillary, carotids)
Quality (blowing, musical, rumbling, machinery)
Pitch (high, medium or low)

20. Holosystolic Murmur Wide pressure gradient throughout systole
Mitral regurgitation/Tricuspid Regurgitation
High pitched blowing, holosystolic heard best at apex, radiating to axilla

21. Holosystolic Murmur
Mitral Insufficiency
Tricuspid Insufficiency

22. Holosystolic Murmurs

23. 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

24. Midsystolic
Aortic Stenosis
Pulmonic Stenosis

25. Early Systolic Murmur Much less common and may be difficult to hear
Acute MR

26. Early Systolic Murmur

27. Murmur
Chronic MR
Acute MR

28. Late Systolic Murmur
Soft or moderately loud, high pitched sounds at LV apex
Malcoaptation of mitral leaflets
MVP late systolic murmurs with a click
Advanced aortic stenosis with decreased or absent S2 and often S4

29. Late Systolic Murmur
MVP
phonocardiogram

31. Early Diastolic Murmur
Occurs 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

32. Early Diastolic Murmur
Acute AI AI

33. Middiastolic murmur Mismatch between diastolic flow and valve size
Mitral stenosis/Tricuspid stenosis
ASD
Severe,chronic AR( Austin Flint)
Left lateral lying position

34. Mid Diastolic Murmur
Mitral Stenosis
Mitral Stenosis

35. Presystolic Sound heard after atrial contraction in diastole
Usually occur with mitral or tricuspid stenosis
Myxoma

36. Continuous Murmurs
Occur 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 arteriosis
Intracardias Shunts

37. Continuous Murmurs
Patent Ductus Arteriosus

39. Benign systolic murmur

41. Echocardiography 2D 3D
Color flow
Doppler (CW and PW)
TDI

42. Echocardiography Valve Morphology Function Associated chamber sizes
Ventricular function
Associated hypertrophy
Pulmonary vein and hepatic vein flow
Pulmonary pressures

43. Purpose of Echocardiography
Identify the primary source of murmur
Define pressure gradients/hemodynamics
Detect secondary lesions
Establish a reference for comparisons
Chamber size and function
In association with exercise in select cases

44. When Echo is probably not necessary
Grade 1 or 2 murmur in absence of suspected endocarditis
Normal systolic ejection pattern
Normal heart sounds
No suggestion of more severe heart disease with provocative maneuvers

45. Echocardiography: Indications Level 1C
Asymptomatic 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

46. Class IIa
Useful 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

47. Class III
Grade 2 or softer midsystolic murmur (innocent murmurs)

48. National Center for Health Statistics 1999-2009
The number of transthoracic echoes have grown by 90 % and TEE by 70%
JACC Vol.60 Suppl
No. 25, 2012

50. 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?

51. Physical Exam BP 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

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

55. 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?

56. 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

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

60. 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?

61. Physical Exam 120/80 pulse 60, regular Normal Carotid upstroke
Regularly Rhythm Early Systolic ejection murmur heard at RUSB 2/6

62. Electrocardiogram

64. Do we need an echo?

65. Questions?