Today, we start our board content. We thought that there is no better way to start than with the heart.
As always, I'm joined by Dr. Andrea Paul from Board Vitals, a company that helps you with your board prep. They feature an amazing QBank and software platform to help you maximize your score. Save 15% off any of their QBank packages by using the promo code BOARDROUNDS at checkout.
Case: A 60-year-old male is undergoing evaluation for a heart murmur. He's asymptomatic and his physician discovers a holosystolic murmur at the cardiac apex. The frequency of that murmur is increased when he expires and an echo confirms that there's a diagnosis to be found.
Question: Compared to a normal patient, which of the following hemodynamic changes would be most likely present?
Note: This involves multi-steps where you have to figure out from the murmur and it's confirming there is something so you could look at the murmur and decide what you think the diagnosis is. From there, you go one step further and say what physiologic effect that would have.
First, you have to know the types of murmurs out there. Holosystolic means that the murmur is present during the entire systole phase. There are some that fade off before the end or would just be a click sound at the beginning of systole.
Holocystolic refers to the sound that is present the entire time. It can be one consistent sound for all systole or maybe it's something that starts at an increased volume or decreases. So you're left with different options.
In this case, it says it's in the cardiac apex. You have to look at other components like the student's age to determine what exactly is causing the murmur. But here we're lucky since they're telling us here that it's right in the apex.
When you're hearing this whole systolic murmur at the cardiac apex, you immediately start to think of mitral valve. When you look at the diagram, you will find different areas where you can picture where the apex of the heart is and what would be causing a sound in that direction. If you're visual, you can picture the mitral valve in the direction of the flow. If it weren't functioning properly, it would be right to the apex of the heart. So this would lead you to suspect mitral valve regurgitation.
Another thing you can think of is mitral stenosis, however, that's diastolic so it would be heard in a similar area at a different time.
Other things to think of when you have mitral valve regurgitation is that it kind of fits with the patient. If the question had said something about an irregular pulse or displaced apex, that would be the first thing that would fit with mitral valve regurgitation as well.
Although the patient here is asymptomatic, common symptoms would be rhematic fever, palpitation, fatigue, shortness of breath, and it can go as far as having signs of heart failure. So any of those components in any combination could be present in the question that would lead to the same answer in the end.
A Increased after load
B Decreased pre-load
C Increased ejection fraction
D Decreased ejection fraction
E Decreased contractility
Now, you have to understand what all of those components mean. In most cases, mitral valve regurgitation would be easily heard during expiration. This specific murmur isn't one that is always so strongly correlated. But this is something to keep in mind that expiration is more positive pressure down on the heart, more pressure on the ventricle and potentially easier to have a bit more of regurgitation.
Afterload is the pressure against...