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

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?

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

HISTORY

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)

Physical Examination

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

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

Murmurs Aortic Stenosis Mitral Regurgitation

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

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

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)

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

Holosystolic Murmur Mitral 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

Midsystolic Aortic Stenosis Pulmonic Stenosis

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

Early Systolic Murmur

Murmur Chronic MR Acute MR

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

Late Systolic Murmur MVP phonocardiogram

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

Early Diastolic Murmur Acute AI AI

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

Mid Diastolic Murmur Mitral Stenosis Mitral Stenosis

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

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

Continuous Murmurs Patent Ductus Arteriosus

Benign systolic murmur

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

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

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

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

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

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

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

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

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 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

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

Electrocardiogram

Do we need an echo?

Questions?