Aortic stenosis causes increased resistance between the left ventricle and systemic circulation. This results in limited cardiac output and subsequent LV hypertrophy.
Character: ejection systolic
Best heard: upper right sternal edge; loudest on expiration
Radiation: carotids and apex
Symptoms:
Exertional dyspnoea
Syncope
Angina (coronary perfusion impaired)
Signs:
Slow-rising pulse
Narrow pulse pressure
Heaving apex beat (pressure-loaded)
Soft or absent S2 (depending on AS severity)
May be signs of LVF (S3, pulmonary oedema)
Causes of… Aortic stenosis
Age (senile calcification; most)
Bicuspid aortic valve (e.g. Turner’s syndrome)
Congenital
Strep-associated (rheumatic heart disease)
Aortic sclerosis
Aortic sclerosis is a hard and inflexible aortic valve (thickened, NOT narrowed) due to age-related calcification. This causes turbulence and a local sound only.
Character: ejection systolic
Best heard: upper right sternal edge
Radiation: does not radiate
Symptoms: none
Signs:
No abnormal signs
Differentiate from AS by normal pulse, apex and S2
Mitral regurgitation
Mitral regurgitation causes backflow of blood from left ventricle to left atrium during systole. This causes LV and left atrial dilation, which ultimately results in pulmonary hypertension.
Character: pansystolic
Best heard: apex; loudest on expiration
Radiation: left axilla
Symptoms:
Dyspnoea
Orthopnoea
Paroxysmal nocturnal dyspnoea
Fatigue
Palpitations
Signs:
AF
Displaced thrusting apex (volume-loaded)
Soft S1
Signs of pulmonary hypertension (RV heave, loud P2)
Mitral valve prolapse is when a mitral valve leaflet prolapses into the left atrium during ventricular systole.
Character: mid-systolic click and/or late systolic murmur
Differentiate from MR by normal S1 then gap before murmur
Best heard: apex; loudest on expiration
Radiation: left axilla and back
Symptoms: atypical chest pain
Signs:
Murmur only
Can develop significant MR
Associations of… Mitral valve prolapse
Primary congenital
Marfan’s syndrome
Polycystic kidney disease
Congenital heart disease
Congestive cardiomyopathy
Hypertrophic obstructive cardiomyopathy
Myocarditis, Ehlers-Danlos
Osteogenesis imperfecta
SLE
Muscular dystrophy
Ventricular septal defect
A ventricular septal defect results in some blood from the left ventricle leaking into the right ventricle during systole. It is usually congenital (chronic), or due to a myocardial infarction (acute).
Character: pansystolic loud machinery-like murmur
Best heard: lover left sternal edge
Radiation: whole precordium
Symptoms: often none if small
Signs:
Signs of pulmonary hypertension (RV heave, loud P2)
If acute, may cause cardiogenic shock
Tricuspid regurgitation
Tricuspid regurgitation results in the backflow of blood from the right ventricle to the right atrium during systole. This causes increased right atrial and venous pressure.
Character: pansystolic
Differentiate from MR by…
louder on inspiration because it’s on the right
Giant JVP
Non-displaced apex
Best heard: lower left sternal edge; loudest on inspiration
Radiation: none
Symptoms:
Fatigue
Hepatic pain on exertion
Ascites
Peripheral oedema
Signs:
Giant ‘v’ waves in JVP (giant JVP waves without RVF = TR)