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 Test your knowledge of murmurs – but don’t worry, the video should help! 

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  • Discuss the basic science relevant to valvular heart disease 
  • Outine the common aetiology of systolic and diastolic murmur
  • Discuss the most common left and, and right, sided heart murmurs 

Approach to the Patient with Heart Murmur

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Question 1

STEM 1 OF 4

A 77YOM presents with recurrent episodes of self-described "faints" and shortness of breath on exertion.  His BP is 110/95 and his radial pulse feels slow to fill.
Which sound is most likely to be absent on auscultation?
A
S1
B
S2
C
S3
D
S4
Question 2

STEM 2 OF 4

Select all the factors below that are most likely to have contributed to this patient's presentation
A
Group A streptococcus infection as a child
B
Cross-reactivity of myocytes to antibodies
C
Degeneration associated with age
D
Deposition of calcium within the leaflets
E
A connective tissue disorder
Question 3

STEM 3 OF 4

Which singular test would best confirm the diagnosis in this patient?
A
ECG
B
FBC
C
LFT
D
ECHO
E
CXR
Question 4

STEM 4 OF 4

Assuming no other risk factors, what is the management of this patient?
A
Amiloride
B
Balloon valvuloplasty
C
Indapamide
D
Palliative
E
Surgical valve replacement
Question 4 Explanation: 
This patient has aortic stenosis. For patients that are symptomatic but stable, surgical valve replacement is the first line management. There may be medical management to bridge the time between diagnosis and surgery, which can involve vasodilators or other medications to reduce the load on the heart. If a patient is critically unstable, a balloon valvuloplasty may be considered, while patients with a less than 1 year life expectancy following surgery are recommended for palliative care.

Two types of valve replacement: aortic valve replacement (AVR) or, for older, higher-risk patients, transcatheter aortic valve implantation (TAVI).

Asymptomatic patients need regular follow-up.

Source: BMJ Best Practice.

Question 5

STEM 1 OF 6

A middle-aged female presents with chronic cough, shortness of breath that is progressing and pain exacerbated with inhalation.  On examination, bilateral lung base crackles are heard and JVP is slightly raised.  A diastolic murmur is heard within the left axilla.
What is the patient's most likely diagnosis?
A
Aortic stenosis
B
Aortic regurgitation
C
Infective endocarditis
D
Mitral stenosis
E
Mitral regurgitation
Question 6

STEM 2 OF 6

The patient's pulmonary capillary wedge pressure is raised significantly.  What is the direct cause of this?
A
Right atrial hypertrophy
B
Right ventricular dilation
C
Left atrial hypertrophy
D
Left ventricular dilation
E
Right atrial dilation
Question 7

Stem 3 of 6

What is the most likely cause of this patient's condition?
A
Group A Streptococcus
B
Group B Streptococcus
C
Pseudomonas aeroginosa
D
Staphylococcus aureus
E
Viridans streptococci
Question 7 Explanation: 
The most common cause of mitral stenosis is Group A Strep which can give rise to rheumatic fever. Mitral stenosis secondary to acute rheumatic fever is called rheumatic heart disease. It is rare in the developed world.
Question 8

STEM 4 OF 6

Given the likely diagnosis above, what is the most common ECG finding you would expect?
A
Bifid P wave
B
PR internval contraction
C
Saw-tooth phenomenon
D
Prolonged QTc
E
Tented T waves
Question 8 Explanation: 
Mitral stenosis can cause a hypertrophied left atrium which can elongate and/or broaden the p wave. Source: The ECG Made Easy, 9th Ed., pg 86
Question 9

STEM 5 OF 6

How is the timing of the murmur described?
A
Pandiastolic
B
Early diastolic
C
Mid diastolic
D
Late diastolic
E
Ejection diastolic
Question 10

Stem 5 of 6

The patient is deemed to have severe symptomatic disease after echocardiography.  What is the first line management in this patient?
A
Surgical valvular replacement
B
Balloon valvuloplasty
C
Furosemide
D
Atenolol
E
Nifedipine
Question 10 Explanation: 
Source: BMJ Best Practice
Question 11

BONUS QUESTION

Further information: The patient is known to be normotensive with no history of stroke, diabetes or cardio-vascular disease.
Given this further information, what would you add to their long term management?
A
Propanolol
B
Ramapril
C
Warfarin
D
Tranexamic acid
E
Nothing
Question 11 Explanation: 
The patient may be at risk of AF and indeed, therefore, of a stroke. However, using CHA2DS2-VASc scoring, the patient scores a 1 due to sex. She is at low risk of thromboembolic events (1.3% per year without medication). You could consider warfarin, though this is at clinical discretion. NB: her pulmonary oedema is reversible with medication and surgery, thus she does not gain the point of CHF.
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