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Aortic Stenosis Aortic Mitral Stenosis Mitral Mitral Valve Tricuspid Valve Pulmonic Valve Multiple and
(AS) Regurgitation (MS) Regurgitation Prolapse Disease Disease Mixed Valvular
(AR) (MR) Heart Disease

Symptoms Cardinal Acute AR: ● asymptomatic Acute MR: ● Most px are TRICUSPID PULMONIC ● Exertional
symptoms: ● Sudden, → symptoms ● Dyspnea asymptomatic STENOSIS STENOSIS dyspnea
● Exertional severe of profound ● Symptoms of ● Arrhythmias ● Pulmonary Mild to moderate: ● Fatigue
dyspnea dyspnea HF left-sided (ventricular congestion ● Asymptomatic ● Palpitations →
● Angina ● Rapid ● Lesser heart failure premature ● Fatigue ● Heart murmur AF; mitral
pectoris cardiac degrees of ● Signs and contractions & ● Severe TS: (or early valve disease
● Syncope decompensat stress → symptoms of paroxysmal dyspnea, systolic click) ● Chest pain
ion dyspnea, pulmonary supraventricul hepatomegaly (compatible
secondary to limited daily edema (e.g., ar and ascites, & Severe: with angina)
heart failure activities, bibasilar, fine, ventricular edema ● Exertional → LV/RV
● Pulmonary orthopnea, late tachycardia) & dyspnea oxygen
edema paroxysmal inspiratory atrial TRICUSPID ● Early-onset supply/
● Symptoms nocturnal crackles) fibrillation → REGURGITATION fatigue demand
related to dyspnea ● Cardiogenic palpitations, ● Fatigue ● Anginal chest mismatch; P/V
underlying ● Fatigue shock: poor light-headedn ● Exertional pain overload
disease (e.g., ● Hoarseness peripheral ess, syncope dyspnea ● Syncope
fever due to ● Dysphagia perfusion, ● Chest pain: ● Cervical * earlier onset of
endocarditis, ● Palpitations tachycardia, often pulsations PULMONIC symptoms
chest pain ● Symptoms of tachypnea, substernal, ● Bloating REGURGITATION
due to aortic embolic and prolonged, & ● Diminished Mild to moderate: Advanced disease:
dissection) disease (e.g., hypotension not related to appetite ● Asymptomatic ● Related to
stroke, ● Palpitations exertion; may ● Muscle ● PA RHF
Chronic AR: mesenteric resemble wasting hypertension (abdominal
● Asymptomati ischemia) Chronic angina ● Progressive fullness/
c mild-to-moderate, pectoris weight gain Severe: bloating;
● Palpitations Later stages: isolated MR: ● Painful ● Fatigue edema)
● Symptoms of ● Symptoms of ● asymptomatic swelling of the ● Exertional
high PP right HF lower dyspnea
○ Water ● Hemoptysis Chronic severe extremities ● Bloating
hammer MR: ● Lower
pulse of ● Fatigue extremity
peripheral ● Exertional swelling
arteries dyspnea
characterize ● Orthopnea
d by rapid ● Palpitations
upstroke ● Symptoms of
 and left-sided HF
downstroke (potentially
○ Corrigan also
pulse symptoms of
○ Traube sign right-sided
○ Duroziez HF)
sign
○ Quincke
sign
○ De Musset
sign
● Symptoms of
left HF

Physical Findings ● Small BP Chronic severe Severe MS: Acute MR: ● A mid-systolic TRICUSPID PULMONIC With mixed aortic
amplitude, AR: ● Malar flush ● Reduced click is a STENOSIS STENOSIS valve disease:
decreased PP ● Jarring of the with pinched arterial diagnostic of Severe cases: Mild or moderate: ● Systolic
● Weak and entire body and blue pressure with MVP ● Hepatic ● Premature murmur
delayed distal ● Bobbing facies a narrow congestion → opening of the should end
pulse (pulsus motion of the ● Normal or pulse Handgrip cirrhosis, elevated RV before S2
parvus et head slightly low pressure maneuver jaundice, end- diastolic
tardus) ● Abrupt systemic ● Normal or ● ↑ murmur of serious (post-atrial a With patent ductus
● Palpable distention and arterial increased and MVP malnutrition, wave) arteriosus:
systolic thrill collapse of the pressure exagerated ● ↓ the duration anasarca, and pressure ● Best heard to
over the larger arteries jugular of the murmur ascites the left of the
bifurcation of are easily venous & delays the ● (+) Distended Severe: upper sternum
the carotids visible pressure and timing of the jugular veins ● Ejection
and the aorta ● LV impulse is waveforms mid-systolic sound moves With a ruptured
heaving and ● Prominent click of MVP With sinus rhythm: closer to the sinus of Valsalva
displaced signs of ● Giant a 1st heart aneurysm:
laterally and pulmonary waves, less sound → ● Continuous
inferiorly congestion conspicuous v inaudible murmur after
● Systolic waves, slow y ● Right-sided an episode of
expansion Chronic severe descent fourth heart acute chest
and diastolic MR: ● Presystolic sound may pain
retraction of ● Normal pulsations of emerge
the apex are arterial the enlarged ● Pulmonic
prominent pressure liver valve closure
● Diastolic thrill ● Sharp, is delayed
may be low-volume TRICUSPID ● Reduced/
 palpable upstroke of REGURGITATION absent
along the left carotid arterial ● (+) Distended pulmonic
sternal border pulse neck veins component of
in ● Systolic thrill ● Prominent c-v the 2nd heart
thin-chested palpable at waves; rapid y sound (P2)
individuals the cardiac descents ● Prominent a
● Prominent apex ● Hepatomegaly wave seen in
systolic thrill ● Hyperdynamic w/ systolic the jugular
may be LV with a brisk pulsations venous pulse
palpable in systolic ● (+) ascites ● Parasternal or
the impulse ● (+) pleural RV lift can be
suprasternal effusions felt
notch and ● (+) edema ● (+)
transmitted ● (+) Hepato- hepatomegaly
upward along jugular reflux ● (+) ascites
the carotid sign ● (+) edema
arteries ● (+) Carvallo’s
sign PULMONIC
REGURGITATION
● (+) Graham
Steell murmur

Auscultation ● Soft S2 Acute AR: ● S1 → Acute MR: ● Crisp TRICUSPID PULMONIC

● S4 is best ● Soft S1 accentuated ● Potentially: S3 mid-systolic STENOSIS STENOSIS
heard at the (loud) and heart sound click ● Often ● Widened S2
apex Chronic AR: slightly ● Apical impulse ● MVP with MR inaudible and delayed
● Early systolic ● S3 delayed not displaced → click with a ● Soft opening P2
ejection click ● Opening snap late-systolic snap
heard after S2 Chronic MR: MR murmur. ● Mid-diastolic
● S2 → closely ● Lateral rumble with PULMONIC
split displacement presystolic REGURGITATION
● Irregular heart of the apical accentuation ● S1: normal
rhythm impulse ● S2: may be
secondary to ● Quiet S1 heart split or
atrial sound TRICUSPID single.
fibrillation ● S3 heart REGURGITATION ● S3/S4, or
sound in ● S1: normal or both:may
advanced barely audible be audible
stages of ● S2: may be
disease split (with a
loud P2 in
 pulmonary
hypertension)
or single
because of
prompt
pulmonic
valve closing
with merger of
P2 and the
A2.
● S3: may be
audible near
the sternum
with RV
dysfunction–in
duced heart
failure.

Characteristics of ● Harsh Acute AR: ● Diastolic Acute MR: ● Mid- or late TRICUSPID PULMONIC AS + AR
Murmur Present crescendo-de ● Soft and short murmur heard ● Soft, (nonejection) STENOSIS STENOSIS ● Mid-systolic,
crescendo early diastolic best at the 5th decrescendo systolic click ● OS of the Mild or moderate: crescendo-
(diamond-sha murmur left intercostal murmur (≥0.14 s after tricuspid ● Mid-systolic, decrescendo
ped), late space at the ● No murmur in S1) valve: ~0.6 s crescendo- (base of the
systolic Chronic AR: midclavicular severe ● High -pitched, after pulmonic decrescendo heart in the
ejection ● High-pitched, line (the apex) regurgitation mid-late valve closure (heard best in 2nd right
murmur that blowing, with LV systolic ● Diastolic the left 2nd interspace), &
radiates decrescendo With severe systolic crescendo- murmur of TS interspace) blowing
bilaterally to diastolic pulmonary HPN: dysfunction or decrescendo has many and is usually decrescendo
the carotids murmur, ● Pansystolic hypotension murmur qualities of the introduced by (along the left
● Best heard in heard best in murmur (“whooping” or diastolic an ejection sternal edge)
the 2nd right the 3rd ICS audible along Chronic MR: “honking”; murmur of MS sound
intercostal along the left the left sternal ● Holosystolic best heard at ● Best heard ● ↑ intensity MS + MR
space sternal border border murmur the apex) along the left during ● Blowing,
● Handgrip ● Austin Flint ● Carvallo’s (high-pitched, lower sternal inspiration holosystolic
decreases the murmur sign blowing) Posterior leaflet border and murmur and a
intensity of the ● Graham ● Radiates to prolapse: over the Severe: mid-diastolic
murmur Severe AR: Steell the left axilla ● Jet of MR is xiphoid ● Systolic rumble
● harsh, murmur and heard directed process murmur may ● Best heard at
crescendo-de best over the anteriorly; ● Most persist the cardiac
crescendo apex (5th murmur will prominent through the apex
midsystolic intercostal radiate to the during aortic
 murmur that space at the base of the presystole in component of TS + TR
resembles the left heart px with sinus the second ● Mimic those of
ejection midclavicular rhythm heart sound left-sided MS
murmur heard line) Anterior leaflet ● Augmented (A2) and MR, save
in aortic ● At least prolapse: during for the
stenosis grade III/VI ● Jet of MR is inspiration; PULMONIC expected
intensity directed reduced REGURGITATION changes in
posteriorly; during ● High-pitched, the murmurs
murmur will expiration and decrescendo with
radiate to the during the diastolic respiration
axilla & back starin phase murmur
of the ● Heard along PS + PR
Click-murmur Valsalva the left sternal ● Murmurs
complex occur maneuver border behave
earlier: ● May become directionally
● Standing TRICUSPID louder with similar to AS
● Strain phase REGURGITATION inspiration and AR
of the ● Blowing, ● Usually
Valsalva holosystolic associated
maneuver murmur along with a loud
● Interventions the lower left and palpable
decreasing LV sternal margin P2 and an RV
volume ● Intensified lift
during
Click-murmur is inspiration
delayed: ● Reduced
● Squatting during
● Isometric expiration
exercises ● Sometimes
confused with
murmur of MR

Reference: Harrison’s, Section 4, Chapters 261-268

Amboss