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The Recognition and Management of Valvular Heart Disease

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The Recognition and Management of Valvular Heart Disease VALVULAR HEART DISEASE THE RECOGNITION AND MANAGEMENT OF VALVULAR HEART DISEASE Discussion of heart murmurs tends to be associated with specialist ward rounds in teaching hospitals, but a good understanding of this clinical sign provides valuable information. AUSCULTATING A HEART MURMUR When does it occur? •Time the murmur in systole or diastole to the first heart sound and by palpating the upstroke of the carotid artery as systole. • Is the murmur early, mild, late, holosystolic, or diastolic? How loud is it? •Grade I — very soft, only heard with special effort • Grade II — soft, faint, but heard immediately • Grade III — moderately loud • Grade IV — so loud that a thrill can be felt •Grade V — very loud, heard with only part of the stethoscope on the chest wall J A KER • Grade VI — heard with the stethoscope removed from the chest wall. MB ChB, MMed (Int), MD Professor Where is it maximal? Department of Internal Medicine • Apex, left parasternal area, aortic area, pulmonary area. School of Medicine Where does it radiate to? University of Pretoria • Neck, axilla, back. Categories of heart murmurs There are three broad categories of heart murmurs: • systolic (murmur begins with S1 or after S1, ends at S2) • diastolic (murmur begins after S2, ends before S1) • continuous (murmur continues without interruption from systole through S2 into diastole. Typical in patent ductus arteriosus). Systolic heart murmurs Systolic murmurs are illustrated in Fig. 1 and are classified as: • early systolic • midsystolic •late systolic • holosystolic (pansystolic) Early systolic murmurs occur in acute severe mitral regurgitation, tricuspid regurgitation (with normal right ventricular (RV) pressures) and ventricular septal defect (VSD). Midsystolic murmurs occur in aortic sclerosis (often in the elderly), aortic stenosis and pulmonary valve stenosis, but can also be a feature of an innocent murmur (common in children, adolescents and young adults). January 2004 Vol.22 No.1 CME 13 VALVULAR HEART DISEASE Diastolic heart murmurs • Elevated jugular venous Diastolic heart murmurs are neither pressure (JVP). This is a sign of benign nor innocent, and begin with heart failure. The patient should be Early systolic or after S2. They are classified as supine at 45°. External jugular follows: pressure can be elevated without S1 A2P2 right heart failure, but internal S 2 Early diastolic murmurs are jugular pressure is more accurate as classic of aortic regurgitation. They a predictor of heart failure. The are best heard with the diaphragm of venous column in the internal vein is Midsystolic the stethoscope, listening at the left very difficult to palpate, but the parasternal area, with the patient pulsations may readily be seen. S1 • Abdomino-jugular reflux sign. A2P2 sitting upright, expiring completely, This is a useful sign to diagnose S2 and leaning forward. Sometimes, with severe pulmonary hypertension, the early heart failure. A positive sign pulmonary valve can become is defined by an increase in JVP of Late systolic regurgitant (Graham Steell’s murmur). greater than 3 cm, sustained for longer than 15 seconds. During the S1 Mid-diastolic murmur. There is a examination the patient is supine A2P2 with the head elevated to 45°. The clear interval after S2 before the S2 murmur starts, the best example being bladder of a sphygmonometer is Holosystolic mitral stenosis. inflated, pressing the bulb 1 - 3 times, after which the bulb must be closed and the partially inflated S1 A2P2 FEATURES OF A HIGH-RISK bladder flat laid flat on the upper S2 HEART MURMUR abdomen. With the open hand the examiner presses the bladder until the mercury column is at 20 mmHg Fig. 1. Systolic murmurs. As a general rule it is necessary to refer a patient with a heart murmur if and keeps it there for 15 seconds any of the features mentioned below while watching the JVP. The patient should breathe normally and not A more sinister cause is mitral are present. The more features hold his/her breath. regurgitation as a result of ischaemic present, the higher the risk. These • Left parasternal heave. A left heart disease. features can be interpreted as being indicative of significant or parasternal heave palpated with the ball of the hand implies RV Late systolic murmurs. The classic pathological heart murmurs. hypertrophy, indicative of cause is mitral valve prolapse, also pulmonary hypertension — a associated with one or more systolic Symptoms complication of valvular disease, clicks. •Effort intolerance, reduced exercise capacity or dyspnoea more than especially mitral valvular disease. Occasionally this left parasternal Holosystolic murmurs are classic grade I (New York Heart heave may be caused by a murmurs of mitral regurgitation and Association). massively enlarged left atrium high-pressure tricuspid regurgitation. •Orthopnoea, or increase in number (especially in mitral valvular A distinctive and diagnostically of pillows used at night, or disease). important feature of tricuspid paroxysmal nocturnal dyspnoea • Loud P . A loud P is indicative of regurgitation is that the murmur (PND). 2 2 pulmonary hypertension. becomes louder with inspiration • Oedema of the ankles. • Cardiomegaly. The normal apex (Carvallo’s sign). The murmur of VSD • Chest pain (angina or angina-like). beat (most lateral, inferior pulsation can also be holosystolic. Systolic • Syncope or pre-syncope could be an on chest) should be in the 5th murmurs that radiate or are associated important symptom of a severe intercostal space (ICS) in the with a palpable thrill are almost aortic valve lesion. midclavicular line. If the apex beat always pathological. Clinical signs is more inferolateral, cardiomegaly Features of a benign or • Blood pressure. Low blood must be considered. innocent heart murmur pressure, a very narrow pulse • High-risk signs on auscultation: The murmur is soft (grade II or less) and pressure (systolic blood pressure • murmur of grade III or more usually midsystolic. It is heard at the left minus diastolic blood pressure), or a • holosystolic murmur sternal edge, it does not radiate and very wide pulse pressure (> 50 • murmur radiating to the neck there are no other cardiac abnormalities. mmHg) could help in the evaluation (carotids), axilla or back of heart murmurs. • diastolic murmurs • Pulse. If the pulse is irregular, • gallop rhythm. consider atrial fibrillation. 14 CME January 2004 Vol.22 No.1 VALVULAR HEART DISEASE • Signs suggestive of infective bladder and fixate it. Close the tubing (mitral stenosis, mitral regurgitation) endocarditis. There are numerous system at the bulb, inflate it with 1 - 3 are particularly prone to develop an minor signs of infective endocarditis, pumps and then close the bulb. The increasing severity of pulmonary e.g. anaemia, fever, splinter patient squeezes the rolled-up bladder hypertension. haemorrhages, haematoma. with the non-dominant hand A positive blood culture is a major maximally, while the doctor reads the • Cardiac failure. Valvular heart sign of infective endocarditis. level of the mercury. The patient disease is an important cause of heart • Signs suggestive of embolism. repeats the manoeuvre, but the failure, which will lead to right heart Stroke in a young person, pressure is kept constantly at 50 - 70% failure. haematuria, or absent pulses in a of the maximum, while the doctor patient with a heart murmur are listens to the heart. During this • Infective endocarditis. A heart indicative of embolism. manoeuvre, there will be a depression murmur, especially of valvular origin, • ECG signs: of the vagus tone and an increase in is a high-risk situation as a result of • no P-waves, with irregular R-R sympathetic tone, which will cause which a patient can easily, during intervals (atrial fibrillation) tachycardia and elevate blood bacteraemias, develop infective • LV or RV hypertrophy pressure and cardiac output. All left- endocarditis. • ST-segment changes or T-wave sided regurgitant murmurs may inversions. decrease. If there is underlying left • Dysrhythmias. A pulse, irregular • Chest X-ray signs: ventricular (LV) dysfunction in in rhythm and volume, is indicative of • cardiomegaly (cardiac size more ischaemic heart disease, an S4 or S3 atrial fibrillation and is a common than 50% of intrathoracic may be elicited by the manoeuvre. complication of valvular disease, diameter) Mitral regurgitation may be elicited if especially mitral valve disease • valvular calcifications (best seen on there is an underlying ischaemic (stenosis and regurgitation). lateral radiograph) papillary muscle. • any sign of pulmonary eodema • Embolism, usually presenting as (Kerley’s B lines, interstitial lines, etc.) Respiration stroke or peripheral arterial disease. • any sign of pulmonary Inspiration increases venous return, hypertension (large pulmonary which will increase RV volume. MANAGEMENT OF VALVULAR cone or large pulmonary artery). Therefore, right-sided S3 or S4 and the systolic murmur of tricuspid DISEASE BEDSIDE MANOEUVRES regurgitation will increase with inspiration. This also holds true for When a cardiac murmur is heard The accuracy of the cardiac physical the murmur of tricuspid stenosis, during routine auscultation of the heart examination for valvular lesions is pulmonary stenosis and pulmonary the following questions should be enhanced by the use of simple regurgitation. asked: bedside manoeuvres that temporarily • Is it systolic or diastolic? alter cardiac haemodynamics. Postural changes •Are there any features of a high-risk The simplest is to let the patient move patient? Valsalva manoeuvre from a standing to a squatting position • Could it be benign? •Are there any complications? Remove the bulb of a while the examiner listens to the heart sphygmomanometer and place the (the latter usually stays seated while If it is not a benign murmur, a rubber tubing leading to it into the listening to the same area). If the diagnosis is necessary. For this patient’s mouth. The patient blows patient is physically unable to do this, purpose referral to a specialist into this tube until the mercury column he/she remains supine while the physician or cardiologist may be is 40 mmHg and continues blowing to examiner bends the patient’s knees necessary.
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