Evaluation of Suspected Valvular Heart Disease in the Outpatient Setting

2. Evaluation of Suspected Valvular Heart Disease in the Outpatient Setting Richard J Gordon, MD., FACC No Financial Relationships to Disclose

3. 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?

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

5. HISTORY

6. 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)

7. Physical Examination

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

9. 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

15. Murmurs Aortic Stenosis Mitral Regurgitation

16. Murmur Pathologic Innocent Diastolic Some systolic murmurs High flow (younger pts, anemia, thyrotoxicosis) Venous hums Mammary souffles Trivial or minimal systolic murmur

17. Murmur 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

19. 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)

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

21. Holosystolic Murmur Mitral Insufficiency Tricuspid Insufficiency

22. Holosystolic Murmurs

23. 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

24. Midsystolic Aortic Stenosis PulmonicStenosis

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

26. Early Systolic Murmur

27. Murmur Chronic MR Acute MR

28. 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

29. Late Systolic Murmur MVP phonocardiogram

31. 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

32. Early Diastolic Murmur Acute AI AI

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

34. Mid Diastolic Murmur Mitral Stenosis Mitral Stenosis

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

36. 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

37. Continuous Murmurs Patent DuctusArteriosus

39. Benign systolic murmur

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

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

43. 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

44. 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

45. Echocardiography: IndicationsLevel 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

46. 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

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

48. 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

50. 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?