Australian Medical Council MCQ examination

A 74 year old man has exertional breathlessness, two episodes of collapse on exertion, and chest tightness climbing stairs. He has a harsh ejection systolic murmur at the right upper sternal edge radiating to both carotids, with a slow-rising, low-volume pulse and a narrow pulse pressure. An echocardiogram shows a small valve area with a high gradient. What is the most likely diagnosis?

1. Heart failure This gives breathlessness and leg swelling but no clear valve murmur. It does not fit the fainting, chest pain and breathlessness together with a slow, weak pulse and a murmur that spreads to the neck.
2. Innocent murmur A soft, harmless murmur with a normal heart. But the fainting, chest pain and breathlessness together with a slow, weak pulse and a murmur that spreads to the neck does not point to it.
3. Acute coronary syndromes This is chest pain from blocked heart arteries, not a valve. Here, the fainting, chest pain and breathlessness together with a slow, weak pulse and a murmur that spreads to the neck points elsewhere.
4. Aortic valve disease correct Correct. A murmur that spreads to the neck, a slow, weak pulse and the three warning signs mean a severe tight aortic valve.
5. Mitral valve disease A mitral valve murmur is heard in a different place and spreads a different way. That does not match the fainting, chest pain and breathlessness together with a slow, weak pulse and a murmur that spreads to the neck.

The point: There are two main aortic valve problems, and you can tell them apart at the bedside. Aortic stenosis is a tight valve. It gives a harsh whooshing murmur at the top right of the chest that spreads to the neck, a slow, weak pulse, and a small gap between the top and bottom blood pressure numbers. The three warning signs are fainting, chest pain and breathlessness on exertion. These mean the valve is dangerous and needs replacing. Aortic regurgitation is a leaky valve. It gives a soft blowing murmur just after the heartbeat at the left of the chest, a bounding pulse, and a wide gap between the blood pressure numbers. An echo (ultrasound of the heart) shows how bad it is and when to treat. A tight valve with symptoms is treated by replacing the valve, either with open surgery or TAVI (a new valve pushed in through a tube), which is common in Australia for older or higher-risk people. A leaky valve is fixed before the heart muscle gets weak. In a tight valve, do not give drugs that widen blood vessels, and be careful with nitrates, because they can drop the blood pressure fast. Antibiotics to prevent valve infection are now given only to high-risk people.

Source: National Heart Foundation of Australia / CSANZ — valvular heart disease National Heart Foundation of Australia / CSANZ · tier 2, specialty society or college

A 74 year old man has exertional breathlessness, two episodes of collapse on exertion, and chest tightness climbing stairs. He has a harsh ejection systolic murmur at the right upper sternal edge radiating to both carotids, with a slow-rising, low-volume pulse and a narrow pulse pressure. An echocardiogram shows a small valve area with a high gradient. What is the most appropriate next step in management?

1. Treat heart failure symptoms cautiously Use water tablets with care in a tight valve. It does not fit the fainting, chest pain and breathlessness together with a slow, weak pulse and a murmur that spreads to the neck.
2. Valve surgery before ventricular failure in severe regurgitation Fix a leaky valve before the heart muscle gets weak. But the fainting, chest pain and breathlessness together with a slow, weak pulse and a murmur that spreads to the neck does not point to it.
3. Endocarditis prophylaxis for high-risk patients Antibiotics before some procedures, only for high-risk people. That does not match the fainting, chest pain and breathlessness together with a slow, weak pulse and a murmur that spreads to the neck.
4. Surgical aortic valve replacement for symptomatic severe stenosis correct Correct. A tight valve that is causing symptoms is treated by replacing the valve.
5. Monitor asymptomatic disease with serial echocardiography Repeat the heart ultrasound until symptoms or the numbers say it is time. Here, the fainting, chest pain and breathlessness together with a slow, weak pulse and a murmur that spreads to the neck points elsewhere.

The point: There are two main aortic valve problems, and you can tell them apart at the bedside. Aortic stenosis is a tight valve. It gives a harsh whooshing murmur at the top right of the chest that spreads to the neck, a slow, weak pulse, and a small gap between the top and bottom blood pressure numbers. The three warning signs are fainting, chest pain and breathlessness on exertion. These mean the valve is dangerous and needs replacing. Aortic regurgitation is a leaky valve. It gives a soft blowing murmur just after the heartbeat at the left of the chest, a bounding pulse, and a wide gap between the blood pressure numbers. An echo (ultrasound of the heart) shows how bad it is and when to treat. A tight valve with symptoms is treated by replacing the valve, either with open surgery or TAVI (a new valve pushed in through a tube), which is common in Australia for older or higher-risk people. A leaky valve is fixed before the heart muscle gets weak. In a tight valve, do not give drugs that widen blood vessels, and be careful with nitrates, because they can drop the blood pressure fast. Antibiotics to prevent valve infection are now given only to high-risk people.

Source: National Heart Foundation of Australia / CSANZ — valvular heart disease National Heart Foundation of Australia / CSANZ · tier 2, specialty society or college