STEPTRACKERCARDIOVASCULAR | PATHOLOGY + PHYSIOLOGY | HIGH-YIELD REVIEW

Valvular Disease & Murmurs

Each valve can be too tight or too leaky — the murmur's timing, location and response to maneuvers name the lesion.

FOCUS ON
Know each lesion's cause, murmur and consequence. AS: calcific or bicuspid, ejection murmur to the carotids, syncope/angina/dyspnea. AR: early diastolic, bounding pulses. MS: rheumatic, opening snap + rumble, AF. MR: holosystolic to the axilla. MVP: mid-systolic click. Then learn the maneuvers.
PICTURE
LESION
CAUSES
MURMUR · SIGNS
CONSEQUENCES
S1S2S1systolediastole
How to read: one heartbeat from S1 to S1 — systole between S1 and S2, diastole after S2. Red = shape and timing of the murmur; teal = ejection click (EC), midsystolic click (MC) or opening snap (OS).
S1S2S1EC
Aortic stenosis
Age-related calcification (> 70); bicuspid valve (50s); rheumatic (with MS)
Crescendo-decrescendo SEM at RUSB → carotids; ejection click (bicuspid); soft S2; pulsus parvus et tardus
Exertional syncope, angina, dyspnea · concentric LVH · schistocytes; Heyde syndrome (GI angiodysplasia bleeding)
S1S2S1
Aortic regurgitation
Root dilation (Marfan, syphilis, HTN, ankylosing spondylitis), bicuspid valve, endocarditis, rheumatic
Early diastolic decrescendo blowing murmur at left sternal border (sit forward, exhale); wide pulse pressure, bounding pulses, head bobbing
Eccentric LVH → HF; Austin Flint rumble
S1S2S1OS
Mitral stenosis
Almost always rheumatic heart disease
Opening snap after S2, then mid-diastolic rumble at apex (left lateral decubitus)
LA dilation → AF, thrombus, stroke; hoarseness (recurrent laryngeal), dysphagia; pulmonary HTN; worse in pregnancy
S1S2S1
Mitral regurgitation
MVP, ischemia (papillary dysfunction/rupture), LV dilation, rheumatic, endocarditis
Holosystolic blowing murmur at apex → axilla; ↑ with handgrip
LA and LV volume overload → HF, AF
S1S2S1MC
Mitral valve prolapse
most common valve lesion
Myxomatous degeneration; Marfan, Ehlers-Danlos, ADPKD
Mid-systolic click + late systolic murmur; click earlier with Valsalva/standing
Usually benign; can cause MR, endocarditis, arrhythmia
S1S2S1
Tricuspid regurgitation
RV dilation (pulmonary HTN), IV-drug endocarditis, carcinoid, Ebstein
Holosystolic at LLSB, ↑ with inspiration; prominent v waves, pulsatile liver
Right HF
S1S2S1EC
Pulmonic stenosis
Congenital (Noonan), carcinoid, tetralogy
SEM at LUSB, ↑ with inspiration; ejection click
RVH
S1S2S1
Carcinoid heart disease
Serotonin from liver metastases reaches the right heart
Tricuspid regurgitation + pulmonic stenosis (plaques on right-sided valves)
Flushing, diarrhea, wheeze; ↑ urine 5-HIAA

Mechanism — pressure vs volume overload

Stenosis (AS)Pressure load
→
Concentric LVHStiff, diastolic dysfunction
Regurgitation (AR, MR)Volume load
→
Eccentric LVH / dilationSystolic failure
Mitral stenosis
→
LA pressure ↑AF, thrombus
→
Pulmonary congestion→ pulmonary HTN → RV failure

Bedside maneuvers

MANEUVER
LOUDER
SOFTER
Inspiration (↑ venous return to right)
Right-sided murmurs
—
Handgrip (↑ afterload)
MR, AR, VSD
AS, HCM
Valsalva / standing (↓ preload)
HCM; MVP click earlier
Most others, incl. AS
Squatting / leg raise (↑ preload)
AS and most murmurs
HCM; MVP click later

How it's tested

COMMON CONFUSIONAS and HCM both cause systolic ejection murmurs. Valsalva softens AS and makes HCM louder.
THE TRAPOnce a patient with severe AS has symptoms (syncope, angina, dyspnea), survival is short without valve replacement. "Watchful waiting" is wrong.
YOUR APPROACHTiming (systolic/diastolic) → location and radiation → extra sounds (click, snap) → maneuver response → cause.

If you see… think…

80-year-old, exertional syncope, SEM to carotids, slow-rising pulse → calcific aortic stenosis
AS with an ejection click in a 50-year-old → bicuspid aortic valve
Aortic stenosis + GI bleeding from angiodysplasia → Heyde syndrome
Bounding pulses, head bobbing, early diastolic murmur → aortic regurgitation
Opening snap + apical diastolic rumble + AF → rheumatic mitral stenosis
Mitral stenosis with hoarseness → enlarged LA compressing the recurrent laryngeal nerve
Holosystolic apical murmur radiating to the axilla → mitral regurgitation
Young woman, palpitations, mid-systolic click → mitral valve prolapse
IV drug user, holosystolic LLSB murmur louder on inspiration → tricuspid regurgitation
Flushing, diarrhea and right-sided valve disease → carcinoid heart disease