2. Introduction
2.5-fold risk of death and 3-fold risk of stroke compared to general population
The New Murmur
Benign or physiological
Do not cause symptoms or findings of cardiovascular disease
Soft, systolic ejection murmurs that begin after S1, end before S2 and no abnormal heart sounds
Systolic murmurs
May be associated with anaemia, sepsis, volume overload or any other cause of increased CO
Look for underlying cause vs. management of murmur itself
Patients without chest pain, dyspnoea, fever or other signs attributable to valvular disease do not
need emergent echo but need referral
Any diastolic murmur or new systolic murmur with symptoms at rest is pathological and needs
inpatient echo
Always consider endocarditis, especially if valvular insufficiency
3. Algorithm for new murmur
Diastolic – Urgent echo
Systolic
Mid-systolic grade 2 (audible but soft)
Asymptomatic
No signs of CVD
Normal ECG and CXR
Murmur does not increase with valsalva or standing
= No further workup
Symptomatic, signs of CVD, abnormal ECG/CXR, murmur increases with Valsalva or standing
= Needs urgent echo
Mid-systolic grade 3 (loud but no thrill)/Early or late systolic/Holosystolic
Needs urgent echo
4. Grading system for murmurs
Grade Description
1 Faint, may not be heard in all positions
2 Quiet but heard immediately
3 Moderately loud
4 Loud
5 Heard with stethoscope partially off chest
wall
6 Heard when stethoscope entirely off chest
wall
5. Valve disorder Murmur Sounds and signs
Mitral stenosis Mid-diastolic rumble, crescendos
to S2
Loud S1, small apical pulse
Mitral regurgitation Acute: Harsh apical systolic
murmur starting with S1 and may
end before S2.
Chronic: High-pitched apical
holosystolic murmur radiating into
S2
S3 +/- S4
Mitral valve prolapse Click with late systolic murmur
crescendos into S2
Mid-systolic click; S2 may be
diminished by late-systolic
Aortic stenosis Harsh ejection systolic murmur Paradoxical split S2 +- S3/4
Small amplitude pulse, slow
rise/sustained peak
Aortic regurgitation High-pitched blowing diastolic
murmur immediately after S2
S3 and wide pulse pressure
6. Mitral stenosis
Rheumatic heart disease is most common
Usually presents with gradual onset pulmonary congestion and AF
Mitral annular calcification is a non-rheumatic cause
Most common in women, elderly and those with HTN/Chronic renal failure
Rarely causes severe symptoms
Clinical features
Exertional dyspnoea, often precipitated by anaemia/sepsis (increased CO)
Systemic emboli are a risk (particularly if in AF)
Haemoptysis is rare but can be massive
Recurrent bronchitis, fatigue, paroxysmal AF
Signs:
Mitral facies (peripheral cyanosis of cheeks)
Mid-diastolic rumbling murmur with crescendo towards S2 (presystolic accentuation disappears if in AF)
S1 usually loud with loud opening snap heard to right of apex
Apical pulse is small and tapping due to underfilled LV
7. Mitral stenosis
Diagnosis and treatment
ECG: Notched or biphasic P waves (P mitrale) and right axis deviation
CXR: Straightening of left heart border (LA enlargement) and later pulmonary congestion
Echo: Severe <1cm2
Medical management
Symptom control
Beta-blockers to reduce HR, increase diastolic filling time
AF with RVR or dyspnoea on exertion may benefit from rate control
Anticoagulation if LA diameter >55mm OR in AF, a left atrial thrombus or history of systemic emboli
Surgical for symptomatic disease
Balloon valvotomy, valve repair or valve replacement before onset of severe pulmonary hypertension
8. Mitral regurgitation
Usually chronic and slowly progressive
Most common cause is fibroelastic deficiency syndrome, seen in the elderly
Mitral valve prolapse is another cause seen in younger patients
Can be secondary to dilated LV with papillary muscle displacement and subsequent
valve dysfunction
Chronic MR
Left atrium dilates to accommodate increased flow to keep pressures normal
Stroke volume is augmeted, maintaining effective forward flow despite backflow
Acute MR
Results in rapid-onset pulmonary congestion and peripheral oedema
Typically due to papillary muscle or chordae tendinae rupture fro MI or valve leaflet
perforation due to IE
9. Mitral regurgitation
Clinical features
Acute MR: Severe dyspnoea, peripheral oedema, tachycardia, cardiogenic shock. S4
gallop and harsh apical systolic murmur loudest in early-mid systole diminishing before
S2
Chronic MR: Eventual exertional dyspnoea, sometimes with AF
Late systolic left parasternal lift and lateral displacement of apex beat
High-pitched holosystolic murmur heard at apex
S1 soft and obscured by murmur
S3 often heard followed by short diastolic rumble, indicating increased flow into the ventricle
Signs of systemic thromboembolism may be first suggestion of MR with AF
10. Mitral regurgitation
Diagnosis
Thinks of acute MR in any patient new-onset and marked pulmonary oedema
Especially if normal heart size on CXR or do not respond to therapy
Look at ECG for anteroinferior ischaemia
Chronic MR
ECG signs of LV hypertrophy and LA enlargement
CXR shows LA and ventricular enlargement proportional to regurgitant volume
11. Mitral regurgitation
Treatment
Acute MR
Oxygen, PPV, nitrates (reduce afteroad, to increase forward flow and restore mitral valve competence as
LV size diminishes
Inotropic support as bridge to surgery (if structural disruption)
Aortic balloon pump may be effective bridge
Medical therapy is aimed at improving forward flow with emergent cardiology and surgical consultation
during optimisation
Chronic MR
Treat acute symptoms
Control AF with RVR using beta-blockers or CCB’s
Start anticoagulation to prevent systemic embolisation
Cardiology consultation
12. Mitral valve prolapse
Systolic billowing of one or both leaflets into the LA with/without mitral regurgitation
Characterised by myxomatous degeneration of the valve due to inherited connective tissue defects
Most common valvular disease in developed countries (2.4% of population)
Presence of concomitant mitral regurgitation determines prognosis
Clnical features
Mostly asymptomatic
May present with atypical chest pain, palpitations, fatigue, anxiety or dyspnoea unrelated to exertion
Signs such as scoliosis, pectus excavatum and low body weight may be seen
If exercise induces symptoms, morbidity increases
Auscultation
Mid-systolic click
Maneuvers that decrease preload (Valsalva/standing) will cause the click to occur earlier in diastole
Increased preload by squatting or hand gripping causes systolic click to move later into systole
A late systolic murmur that crescendos into S2 is heard in some
13. Mitral valve prolapse
Diagnosis and therapy
Emergency evaluation focuses on identification of long-term complications such as AF or
heart failure
Refer to cardiologist if suspected
Palpitations attributable to mitral valve prolapse may respond to beta-blockers but
should be left to cardiologist
Antithrombotic therapy only indicated if TIA/stroke or AF
If prolapse and MR, require endocarditis prophylaxis
14. Aortic stenosis
Most common cause in developed countries is degenerative calcification,
associated with increased age, smoking, dyslipidaemia and diabetes
Rheumatic heart disease is the most common cause worldwide
Bicuspid aortic valves and congenital heart disease are also seen
3% prevalence if >74 years old
Typically long asymptomatic period with LV hypertrophy to preserve EF
Ultimately LV hypertrophy impairs filling and increases myocardial oxygen demand with
slow reduction in cardiac output, coronary and systemic blood flow
15. Aortic stenosis
Clinical features
Classic triad: Dyspnoea, chest pain and syncope
Many patients with severe stenosis (<1cm2) are asymptomatic
Often stepwise dyspnoea, followed by chest pain, then syncope and finally signs of heart failure
Once symptoms start, mortality increases
Physical exam
Late peaking systolic murmur at right 2nd ICS, radiating to carotids, with single or paradoxically split S2, S4 gallop and
reduced carotid pulse with delayed upstroke and long plateau (pulsus parvus et tardus)
Brachioradial delay is also seen
Narrowed pulse pressure
AS with AF = Dire consequences
AS typically have diastolic dysfunction due to LV hypertrophy and are reliant on atrial kick for filling
If then given GTN for chest pain or dyspnoea, can collapse
16. Aortic stenosis
Diagnosis
ECG: LV hypertrophy + LBBB or RBBB in 10%
Late CXR findings are LV hypertrophy (not dilation) and pulmonary congestion
Treatment
APO: Oxygen, PPV. Use nitrates, beta-blockers, CCB’s and diuretics with caution
Reducing preload or afterload can cause significant hypotension
New-onset AF may require cardioversion urgently
If newly symptomatic, admit
Without surgery 40-50% mortality within 1 year
If discharged, need to avoid vigorous activity and need prompt review by Cardiologist.
Prophylactic antibiotics for endocarditis are not required
Need valve replacement as soon as symptomatic, asymptomatic with LV dysfunction or if jet peak
velocity >4m/s
17. Aortic regurgitation
Slowly progressive over years
Ultimately leads to LV dilatation and hypertrophy
Get wide pulse pressures
Tachycardia shortens diastole, which decreases regurgitant volume and mutes symptoms early on
In contrast, increased afterload e.g. exercise, exacerbates regurgitant flow and may precipitate
symptoms
Over time, increased LV dilatation and hypertrophy leads to impaired systolic function and reduced
CO with failure symptoms
50% of cases due to leaflet disorders secondary to bicuspid aortic valves, infective endocarditis or
rheumatic heart disease
Non-valvular causes include aortic dissection, aort root dilatation (Marfan’s) or aortitis
Also frequently associated with aortic stenosis and can be severe in this case
18. Aortic regurgitation
Clinical features
Acute:
Rapid dyspnoea, pulmonary oedema, tachycardia and cardiogenic shock
Sudden onset ripping or tearing pain suggests acute aortic dissection
Fever or IVDU suggests endocarditis
Exam
High-pitched blowing diastolic murmur immediately after S2 at left sternal border 2/3rd ICS
May get systolic ejection murmur due to increased SV and S3 due to ventricular dilatation also
Austin Flint murmur (mid-diastolic rumble) may be heard in left lateral position at apex using Bell of
stethoscope
Widened pulse pressure
Corrigan (water-hammer) pulse
19. Aortic regurgitation
Exam
Accentuated praecordial apex beat
Pulsus bisferiens (small then strong and broad pulse – biphasic)
Duroziez sign (to-and-fro femoral murmur)
De Musset sign (head bobbing)
Quincke sign (capillary pulsations visible at proximal nail bed when pressure applied to tip)
Chronic AR:
Exertional dyspnoea or fatigue
Chest pain due to myocardial ischaemia due to low diastolic pressures and coronary flow
Palpitations due to large stroke volume or PVC’s
Symptoms of LV failure occur late
20. Aortic regurgitation
Diagnosis
Acute AR
CXR may show acute pulmonary oedema without cardiac enlargement (if acute)
May shows signs of dissection
ECG
Sinus tachycardia
Ischaemic changes or ST elevation due to dissection involving coronary arteries
Chronic AR:
CXR: Cardiomegaly, aortic dilatation, evidence of heart falure
ECG: LV hypertrophy
21. Aortic regurgitation
Treatment
Acute: Immediate surgical intervention
Medical: Oxygen, intubation for respiratory failure, nitroprusside + inotropes can augment forward flow
and reduce LV end-diastolic pressure
Diuretics and nitrates are usually ineffective
Beta-blockers are CI in acute aortic regurgitation (commonly used in aortic dissection but if acute
aortic regurgitation co-exists, do better with tachycardia to reduce time/volume of regurgitation flow
Aortic balloon pumps are also contraindicated as worsen regurgitant flow
If mild AR due to endocarditis, antibiotics may be sufficient without operative intervention
Chronic AR:
Vasodilators e.g. ACEi, dihydropyridines
Those who are symptomatic, have low EF or who have significant LV dilatation – consider aortic valve
replacement
22. Right-sided valve disease
Trivial TR and PR are common
Pathological TR usually in setting of:
Elevated right sided pressure or volume overload
E.g. Pulmonary hypertension, chronic lung disease, PE or atrial septal defects
Tricuspid stenosis is rare and usually accompanied by regurgitation
Pulmonic valve is least likely to be affected by acquired disease
Acute onset tricuspid disease is usually due to endocarditis, and typically
aggressive organisms (e.g. S. aureus)
23. Right-sided valve disease
Clinical
Right heart failure signs and symptoms
Exertional dyspnoea is often the first symptoms if associated with pulmonary
hypertension
Tricuspid regurgitation
Murmur is soft, blowing and holosystolic along left lower sternal edge and increases with
respiration
Systolic waveform may be seen in JVP in severe TR
Tricuspid stenosis
Rumbling crescendo-decrescendo diastolic murmur before S1
Along left lower sternal edge, increases with inspiration and often preceded by opening snap
24. Right–sided valvular disease
Exam
Pulmonic stenosis
Exertional dyspnoea, syncope, chest pain and signs of right heart failure
Harsh systolic murmur, best head in left 2nd ICS, increased with inspiration
Pulmonic regurgitation
High-pitched and blowing diastolic murmur (Graham Steell murmur) increased with inspiration
Best heard over left 2nd/3rd ICS
Typically have right ventricular thrill and heave
25. Right-sided valvular disease
Treatment
Treat underlying cause
Diuretics treated effects of elevated venous pressures but need to use with caution to
avoid volume depletion (as reliant on preload) and electrolyte abnormalities
If symptomatic pulmonic or tricuspid stenosis, may be candidates for balloon valvotomy
Severe TR due to structural valve abnormality may require valve replacement
26. Prosthetic valve disease
Mechanical
Valve thrombosis or thromboembolism rate 8% per year (1-2% with anticoagulation)
Embolic risk highest in first 3 post-operative years
Emboli more common from mitral than aortic valves
Major bleeding complications on warfarin 1.4% per year
Antiplatelet therapy is recommended for all patients with any prosthetic valve
Complications
Thrombosis
Dehiscence of sutures
Gradual degeneration
Sudden fracture
Symptoms are usually slowly progressive but acute failure and death can occur
27. Prosthetic valve disease
Prosthetic valve endocarditis
Occurs in 6% of patients within 5 years of surgery
Early causes (first year) include S. epidermidis and S. aureus
Late cases usually the same as native valves (Strep viridans, Serratia, Pseudomonas
28. Prosthetic valve disease
Clinical features
Cardiac remodelling persists despite valve replacement
Patients are likely to have concomitant CAD, systemic hypertension, LV failure or AF
Acute onset of respiratory distress, APO or cardiogenic shock
Think mechanical valve failure, tearing of a bioprosthesis or large clot obstructing the valve and preventing closure
Paravalvular leak can also present with AHF
Slowly progressive HF can occur with gradual thrombus formation
Mechanical valves often have loud metallic sounds
Aortic valves often have systolic murmurs but diastolic murmurs should always be considered pathological
A ‘quiet’ mechanical valve is concerning
Aortic bioprostheses usually cause a short mid-systolic murmur
Mitral bioprostheses usually cause a short diastolic rumble
Loud holosystolic murmur indicates dysfunction
29. Prosthetic valve dysfunction
Diagnosis of dysfunction and complications
Consider this in any patient with a valve replacement and new or progressive dyspnoea, CCF,
decreased exercise tolerance or pain
Suspect thromboembolism, septic embolism or ICH in any patient with prosthetic valve and
new neurological deficit (like AF)
Consider endocarditis in patient with prosthetic valve and persistent fever/fever without source
Treatment and disposition
Cardiology and cardiothoracic consult
Emergent surgery and thrombolytic therapy are options for thrombotic complications
Lesser degrees of obstruction may simple require optimisation of anticoagulation
Obtain consultation on all if suspicious for complication
30. Prosthetic valve dysfunction
Reversal of anticoagulation in the ED
Mechanical mitral valves INR 2.5-3.5 target
Bileaflet mechanical valves in aortic position INR 2-3
Aspirin for all patients with prosthetic valves
If INR 5-10 without bleeding: Withold warfarin and consider IV Vit K 1-2.5mg
If Severe bleeding, give FFP + prothrombinex 50IU and avoid high-dose Vitamin K due to
risk of overcorrection
31. Pregnant women with valvular disease
Increased CO and blood volume
Accentuate murmurs in mitral and aortic stenosis
Reduced SVR
May attenuate aortic or mitral regurgitant murmurs
Asymptomatic mild lesions are well tolerated
Symptomatic disease, pulmonary HTN or LV dysfunction requires high-risk obstetric follow-up
Neonatal complications associated:
Prematurity
IUGR
RDS
Intraventricular haemorrhage
Death
Mild disease: medical Rx
Moderate or severe stenotic valvular disease: Balloon valvotomy or surgery
Aortic or mitral regurgitation who have severe symptoms may also require surgery
Endocarditis prophylaxis is not required for delivery
32. Pregnant women with valvular disease
Presentations during pregnancy
Extremis, dyspnoea, pulmonary oedema, angina, syncope
Hypercoagulable state makes native dysfunctional or prosthetic valve thrombosis more
likely and anticoagulation is recommended (LMWH or UFH)
Low-dose aspirin is recommended in 2nd and 3rd trimesters for pregnant patients with
mechanical or bioprosthetic valves