Common Valvular Heart Disease (at a glance)
Features /Points Mitral Stenosis
Peripheral Signs (Pulse) Low volume pulse,
normal in rhythm &
character or irregularly
irregular (Atrial
fibrillation)
Mitral facies (Malar
flush)
Palpation Apex Tapping
beat Others : RV heave, loud
P2 (pulmonary
hypertension)
Thrill Diastolic apical thrill
Auscultation Heart Loud first heart sound
sound and opening snap
Murmur Low pitched, localized,
rough, rumbling,
Mid diastolic murmur
Best heard with bell of
stethoscope in left lateral
position and breathe hold
after expiration.
Symptoms • Breathlessness
• Fatigue
• Oedema, ascites
• Palpitation
• Haemoptysis
• Cough
• Chest pain
• Thromboembolic
complications (e.g.
stroke, ischaemic limb)
Investigations ECG • Right ventricular
hypertrophy: tall R waves
in V1–V3
• P mitrale or atrial
fibrillation
Chest X- • Enlarged LA &
ray Appendage
(Straightening of Lt
border of heart, Double
shadow in Rt border of
heart)
• Signs of pulmonary
venous congestion
(Kerley B line, Widening
of carina)
Mitral Aortic Stenosis Aortic Regurgitation
Regurgitation
Normal Low volume slow High volume, Collapsing
Atrial rising pulse & Narrow pulse.
fibrillation/flutter pulse pressure Dancing Carotid pulse.
Quincke’s sign – Capillary
pulsation in nail beds.
de Musset’s sign – Head
nodding with each pulse.
 Duroziez’s sign – Pistol shot
murmur/bruit over femoral
artery.
Hills sign – Higher BP in legs
than arms.
Mueller’s sign – Pulsation in
uvula with heart beat.
Three BP – High systolic, Low
diastolic, Wide pulse pressure.
Thrusting, active and Thrusting apex beat (LV Displaced, heaving apex beat
rocking (Volume pressure overload) (Volume overload)
overload)
Systolic apical thrill Systolic apical thrill Diastolic apical thrill
Soft S1, apical S3 Soft second heart Fourth heart sound
Sound 1st & 2nd heart sound normal
Loud, blowing in Harsh, high pitched High pitch, blowing
character and musical  Early diastolic murmur
Pansystolic murmur Ejection systolic Best heard in left lower para
Best heard at the apex murmur sternal area (3rd or 4th space)
that radiate to left Best heard in aortic with patient sitting and leaning
axilla. area and radiate to right forward and breath hold after
side of the neck. expiration.
Other murmur :
• Systolic murmur (increased
stroke volume)
• Austin Flint murmur (soft
mid-diastolic)
• Dyspnoea (pulmonary • Mild or moderate Mild to moderate aortic
venous congestion) stenosis: regurgitation
• Fatigue (low cardiac usually asymptomatic • Often asymptomatic
output) • Exertional dyspnoea • Awareness of heart beat,
• Palpitation (atrial • Angina ‘palpitations’
fibrillation, increased • Exertional syncope Severe aortic regurgitation
stroke volume) • Sudden death • Breathlessness
• Oedema, ascites (right • Episodes of acute • Angina
heart failure) pulmonary oedema
• Left atrial hypertrophy • Left ventricular • Initially normal, later left
(if not in atrial hypertrophy (usually) ventricular hypertrophy and T-
fibrillation) • Left bundle branch wave inversion
• Left ventricular block
hypertrophy
• Enlarged LA • May be normal; • Cardiac dilatation, maybe
• Enlarged LV sometimes enlarged LV aortic dilatation
• Pulmonary venous and dilated • Features of left heart failure
congestion ascending aorta on PA
• Pulmonary oedema (if view, calcified valve on
acute) lateral view