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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}
|QuestionAuthor={{Rim}} {{Alison}}
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pathology
|MainCategory=Pathology
Line 20: Line 20:
|MainCategory=Pathology
|MainCategory=Pathology
|SubCategory=Cardiology
|SubCategory=Cardiology
|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?
|Prompt=A 62-year-old female presents to the physician’s office for multiple syncopal episodes.  The patient reports that she has not been feeling well lately and is fatigued. 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?
|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]].  
|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.   
The severity of AS murmur is associated with several findings regarding history, physical exam, and work-up.  The manifestation of symptoms is associated with severity. 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]].   
[[Hypertrophy]] is considered an adaptive response of the valvular disease.  When the compliance of the left ventricle is reduced,  the [[LV diastolic pressure]] ([[LVDP]]) increases and the LV wall thickens to cause decreased [[coronary artery blood flow]] and [[coronary flow reserve]], manifesting in [[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.
As AS becomes more severe, the duration of the murmur increases and peaks at mid to late [[systole]].  Early peak correlates with less severe [[stenosis]], while late peak correlates with AS. 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.
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, as well as calculating aortic valve area.


Educational Objective:
|EducationalObjectives= The severity of AS murmur is associated with several findings on history, physical exam, and work-up.  Intensity of the murmur does not correlate with the severity of AS.
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:
|References= Maganti K, Rigolin VH, Bonow RO. Valvular heart disease: diagnosis and management. Mayo Clin Proc. 2010;85(5):483-500
Maganti K, Rigolin VH, Bonow RO. Valvular heart disease: diagnosis and management. Mayo Clin Proc. 2010;85(5):483-500
|AnswerA=Time for murmur to peak
|AnswerA=Time for murmur to peak
|AnswerAExp=Time for murmur to peak correlates with severity of AS.
|AnswerAExp=The amount of time it takes for the murmur to peak correlates with the severity of AS.
|AnswerB=Intensity of the murmur
|AnswerB=Intensity of the murmur
|AnswerBExp=Intensity of murmur does not correlate with AS severity.
|AnswerBExp=The intensity of murmur does not correlate with AS severity.
|AnswerC=Onset of symptoms
|AnswerC=Onset of symptoms
|AnswerCExp=Onset of symptoms correlates with AS severity and is an indication for surgical intervention.
|AnswerCExp=The onset of symptoms correlates with AS severity and is an indication for surgical intervention.
|AnswerD=Presence of left ventricular (LV) hypertrophy
|AnswerD=Presence of left ventricular (LV) hypertrophy
|AnswerDExp=Presence of LV hypertrophy correlates with AS severity.
|AnswerDExp=Presence of LV hypertrophy correlates with AS severity.
|AnswerE=Aortic valve area
|AnswerE=Aortic valve area
|AnswerEExp=Aortic valve area measured by Doppler echocardiography is directly related to the severity of AS.
|AnswerEExp=Aortic valve area, measured by Doppler echocardiography, is directly related to the severity of AS.
|RightAnswer=B
|RightAnswer=B
|WBRKeyword=aortic, stenosis, valve, severity, valvulopathy, murmur, crescendo, decrescendo, ejection, click, carotid, second, intercostal, space, time, peak, intensity
|WBRKeyword=aortic stenosis, AS, cardiology, cardiovascular system, valvulopathy, murmur, ejection, intercostalspace,
|Approved=No
|Approved=Yes
}}
}}

Revision as of 13:15, 23 July 2014
Author [[PageAuthor::Rim Halaby, M.D. [1] (Reviewed by Alison Leibowitz)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pathology
Sub Category SubCategory::Cardiology
Prompt [[Prompt::A 62-year-old female presents to the physician’s office for multiple syncopal episodes. The patient reports that she has not been feeling well lately and is fatigued. 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::The amount of time it takes for the murmur to peak correlates with the severity of AS.
Answer B AnswerB::Intensity of the murmur
Answer B Explanation AnswerBExp::The intensity of murmur does not correlate with AS severity.
Answer C AnswerC::Onset of symptoms
Answer C Explanation AnswerCExp::The 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 regarding history, physical exam, and work-up. The manifestation of symptoms is associated with severity. 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 the left ventricle is reduced, the LV diastolic pressure (LVDP) increases and the LV wall thickens to cause decreased coronary artery blood flow and coronary flow reserve, manifesting in chest pain. As AS becomes more severe, the duration of the murmur increases and peaks at mid to late systole. Early peak correlates with less severe stenosis, while late peak correlates with AS. 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, as well as calculating aortic valve area.
Educational Objective: The severity of AS murmur is associated with several findings on history, physical exam, and work-up. Intensity of the murmur does not correlate with the severity of AS.
References: Maganti K, Rigolin VH, Bonow RO. Valvular heart disease: diagnosis and management. Mayo Clin Proc. 2010;85(5):483-500]]

Approved Approved::Yes
Keyword WBRKeyword::aortic stenosis, WBRKeyword::AS, WBRKeyword::cardiology, WBRKeyword::cardiovascular system, WBRKeyword::valvulopathy, WBRKeyword::murmur, WBRKeyword::ejection, WBRKeyword::intercostalspace
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