WBR0439

Author	[[PageAuthor::Rim Halaby, M.D. [1]]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Pathology
Sub Category	SubCategory::Cardiology
Prompt	[[Prompt::A 62 year old female patient who is previously healthy presents to the physician’s office for multiple syncopal episodes. The patient reports that she has not been feeling well lately and she is fatigued all the time. She denies other associated symptoms or use of any medication. On cardiac auscultation, the physician hears a systolic crescendo-decrescendo murmur with ejection click best heard at the right second intercostal space that radiates to the carotids. Which of the following findings is most likely not associated with severity of the patient’s murmur?]]
Answer A	AnswerA::Time for murmur to peak
Answer A Explanation	AnswerAExp::Time for murmur to peak correlates with severity of AS.
Answer B	AnswerB::Intensity of the murmur
Answer B Explanation	AnswerBExp::Intensity of murmur does not correlate with AS severity.
Answer C	AnswerC::Onset of symptoms
Answer C Explanation	AnswerCExp::Onset of symptoms correlates with AS severity and is an indication for surgical intervention.
Answer D	AnswerD::Presence of left ventricular (LV) hypertrophy
Answer D Explanation	AnswerDExp::Presence of LV hypertrophy correlates with AS severity.
Answer E	AnswerE::Aortic valve area
Answer E Explanation	AnswerEExp::Aortic valve area measured by Doppler echocardiography is directly related to the severity of AS.
Right Answer	RightAnswer::B
Explanation	[[Explanation::Aortic stenosis (AS) is the most common valvulopathy in the Western world. AS is characterized by a triad of symptoms: syncope, angina, and dyspnea. On physical examination, AS is a systolic crescendo-decrescendo murmur with an ejection click that is best heard at the right sternal border, or the “aortic site”. AS murmur typically radiates to the carotids. The severity of AS murmur is associated with several findings on history, physical exam, and work-up findings. The presence of symptoms is associated with severity, where surgery is indicated as soon as symptoms develop because average survival is less than 5 years after development of symptoms. Hypertrophy is considered an adaptive response of the valvular disease. When the compliance of LV is reduced, the LV diastolic pressure (LVDP) increases and the LV wall thickens to cause decreased coronary artery blood flow and coronary flow reserve leading to chest pain. As AS becomes more severe, the duration of the murmur increases and thus peaks at mid to late systole. Hence early peak correlates with less severe stenosis, while late peak correlates with AS. Conversely, the intensity of the murmur does not correlate with severity of disease. Finally, patients with AS have aortic valve thickening with reduced aortic valve area. Doppler echocardiography is an appropriate test to evaluate severity of AS by measuring jet velocity and gradients and calculating aortic valve area. Educational Objective: The severity of AS murmur is associated with several findings on history, physical exam, and work-up findings. Intensity of the murmur does not correlate with the severity of AS. Reference: Maganti K, Rigolin VH, Bonow RO. Valvular heart disease: diagnosis and management. Mayo Clin Proc. 2010;85(5):483-500 Educational Objective: References: ]]
Approved	Approved::No
Keyword	WBRKeyword::aortic, WBRKeyword::stenosis, WBRKeyword::valve, WBRKeyword::severity, WBRKeyword::valvulopathy, WBRKeyword::murmur, WBRKeyword::crescendo, WBRKeyword::decrescendo, WBRKeyword::ejection, WBRKeyword::click, WBRKeyword::carotid, WBRKeyword::second, WBRKeyword::intercostal, WBRKeyword::space, WBRKeyword::time, WBRKeyword::peak, WBRKeyword::intensity
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::