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VALVULAR HEART DISEASE
1) A 71-year-old woman with chronic aortic regurgitation complains of worsening dyspnea on
exertion, orthopnea, fatigue, and angina. She is anxious because of an unpleasant awareness
of her heartbeat. Her cardiac silhouette is enlarged, with uncoiling and enlargement of the
aortic root seen on chest x-ray. She has a widened pulse pressure, rapidly rising and falling
carotid pulse, spontaneous nail-bed pulsations, and a to-and-from murmur over the femoral
artery. You find that her systolic blood pressure measured over the femoral artery is 45 mm
Hg higher than her systolic blood pressure measured over the ipsilateral brachial artery. She
has normal S1 and S2 followed by a blowing, diastolic murmur best heard along the left
sternal border. Which of the following classical signs of chronic aortic regurgitation is
absent in this patient?
A diastolic murmur over the femoral artery (Duroziez’s sign)
Rhythmic bobbing of the head (De Musset’s sign)
A visible capillary pulse (Quincke’s pulse)
Rapid upstroke and collapse of the carotid pulse (Corrigan’s pulse)
difference of systolic blood pressure of 40 mm Hg or higher at the femoral artery than at the
ipsilateral brachial artery (Hill sign)
2) You are examining a 69-year-old man who is complaining of dyspnea and chest pain. He has
a history of a heart murmur, which has been present for a long time, but no exact data are
available as to its nature in the past. The mid-diastolic rumble that you hear is an Austin-
Flint murmur. What is known about this type of murmur?
It reflects rapid filling of the left ventricle.
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It is caused by a high transmitral gradient during diastole.
It is produced when the regurgitant aortic jet impinges on the mitral valve and causes it to
vibrate.
It occurs when the chordae tendineae are stretched out in midsystole by the prolapsing mitral
valve.
It is best heard during diastole at the left sternal border.
3) A 30-year-old man presents with progressive dyspnea on exertion over the last few
months. His medical history is notable for hypertension, for which he takes
hydrochlorothiazide 25 mg daily. On examination, he has a 3/6 systolic murmur in the left
upper sternal area that does not radiate to the carotids. The murmur is increased with
Valsalva maneuvering and is decreased with squatting. He has no jugular venous
distension or peripheral edema. What is the likely diagnosis?
Hypertrophic obstructive cardiomyopathy
aortic stenosis
pulmonic stenosis
aortic regurgitation
mitral valve prolapse
4) A 65-year-old patient who used to travel the world presents to you for evaluation. He has no
active complaints, although a review of systems reveals a gradual increase in shortness of
breath that the patient attributes to the "normal aging process." The patient is proud of the
fact that he has never needed a physician and has lived in good health in many countries. He
also mentions that he had multiple sexual partners "all over the world." On examination, he
has a 3/6 diastolic blowing decrescendo murmur along the right sternal border that is softer
with inspiration and louder with squatting. His extremities show no edema, but a chronic
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sore is noted below his right knee. Electrocardiography shows left atrial enlargement.
Echocardiography shows moderate aortic regurgitation with an ejection fraction of 45%.
Which of the following tests is indicated to evaluate his murmur?
adenosine tracer stress testing
rapid plasma reagin
blood cultures
HIV serology
human leukocyte antigen (HLA) typing
5) You are following up with a man aged 65 years after he received treatment for hypertension.
His only complaint is shortness of breath with moderate to heavy exertion, but he tells you
that it does not occur at rest or when he is performing light activity. His medical history is
only notable for hypertension, for which he takes hydrochlorothiazide and metoprolol. He
does not smoke or drink alcohol. On examination, he has a 2/6 systolic murmur at the right
upper sternal border radiating to the carotids. Echocardiography shows mild left ventricular
hypertrophy, an ejection fraction of 55%, and a bicuspid aortic valve with aortic valve area
of
0.9 cm2. What is the appropriate management for his valve disease?
treadmill stress testing
digoxin
left heart catheterization with valvuloplasty
aortic valve replacement
beginning enalapril
6) A 35-year-old woman is seen for palpitations that occur a few times per week. She has no
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notable medical history, and her only medication is an oral contraceptive. She does not
smoke or drink alcohol. She works as a city garbage collector. Her vital signs are:
temperature 37.2 °C, heart rate 77 beats/minute and regular, blood pressure 115/75 mm Hg,
respiratory rate 18 breaths/minute, and oxygen saturation 99% on room air. On cardiac
examination, her heart rate is regular with a normal S1 and S2, a midsystolic click followed
by a late systolic murmur at the apex. During the straining phase of the Valsalva maneuver,
the click occurs earlier, and the murmur is more intense. Findings on electrocardiography are
normal. Holter monitor shows occasional premature ventricular contractions and premature
atrial contractions only. What is the most appropriate management in this patient's
condition?
nitroglycerin 0.4 mg sublingual as needed
digoxin
echocardiography
aspirin 500 mg per day
reassurance and low-dose metoprolol
7) A 45-year-old woman presents to you at the request of her dentist. The patient has a medical
history of mitral valve prolapse and takes no medications. She has no symptoms other than
tooth pain. She does not smoke or drink alcohol. She works as a city garbage collector. Her
vitals are: temperature 37.0 °C, heart rate 77 beats/minute and regular, blood pressure 115/75
mm Hg, respiratory rate 18 breaths/minute, and oxygen saturation 99% on room air.
Examination of the head, eyes, ear, nose, and throat, as well as lung, abdominal, and
neurologic examinations are normal. On cardiac examination, the rhythm is regular with a
normal S1 and S2, a midsystolic click followed by a late systolic murmur at the apex. With
squatting, the click and murmur occur later. Findings on electrocardiography are normal.
Transthoracic echocardiography shows thickened mitral valve leaflets that prolapse above
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VALVULAR HEART DISEASE
1) A 71-year-old woman with chronic aortic regurgitation complains of worsening dyspnea on
exertion, orthopnea, fatigue, and angina. She is anxious because of an unpleasant awareness
of her heartbeat. Her cardiac silhouette is enlarged, with uncoiling and enlargement of the
aortic root seen on chest x-ray. She has a widened pulse pressure, rapidly rising and falling
carotid pulse, spontaneous nail-bed pulsations, and a to-and-from murmur over the femoral
artery. You find that her systolic blood pressure measured over the femoral artery is 45 mm
Hg higher than her systolic blood pressure measured over the ipsilateral brachial artery. She
has normal S1 and S2 followed by a blowing, diastolic murmur best heard along the left
sternal border. Which of the following classical signs of chronic aortic regurgitation is
absent in this patient?
A diastolic murmur over the femoral artery (Duroziez’s sign)
Rhythmic bobbing of the head (De Musset’s sign)
A visible capillary pulse (Quincke’s pulse)
Rapid upstroke and collapse of the carotid pulse (Corrigan’s pulse)
difference of systolic blood pressure of 40 mm Hg or higher at the femoral artery than at the
ipsilateral brachial artery (Hill sign)
2) You are examining a 69-year-old man who is complaining of dyspnea and chest pain. He has
a history of a heart murmur, which has been present for a long time, but no exact data are
available as to its nature in the past. The mid-diastolic rumble that you hear is an Austin-
Flint murmur. What is known about this type of murmur?
It reflects rapid filling of the left ventricle.
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It is caused by a high transmitral gradient during diastole.
It is produced when the regurgitant aortic jet impinges on the mitral valve and causes it to
vibrate.
It occurs when the chordae tendineae are stretched out in midsystole by the prolapsing mitral
valve.
It is best heard during diastole at the left sternal border.
3) A 30-year-old man presents with progressive dyspnea on exertion over the last few
months. His medical history is notable for hypertension, for which he takes
hydrochlorothiazide 25 mg daily. On examination, he has a 3/6 systolic murmur in the left
upper sternal area that does not radiate to the carotids. The murmur is increased with
Valsalva maneuvering and is decreased with squatting. He has no jugular venous
distension or peripheral edema. What is the likely diagnosis?
Hypertrophic obstructive cardiomyopathy
aortic stenosis
pulmonic stenosis
aortic regurgitation
mitral valve prolapse
4) A 65-year-old patient who used to travel the world presents to you for evaluation. He has no
active complaints, although a review of systems reveals a gradual increase in shortness of
breath that the patient attributes to the "normal aging process." The patient is proud of the
fact that he has never needed a physician and has lived in good health in many countries. He
also mentions that he had multiple sexual partners "all over the world." On examination, he
has a 3/6 diastolic blowing decrescendo murmur along the right sternal border that is softer
with inspiration and louder with squatting. His extremities show no edema, but a chronic
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sore is noted below his right knee. Electrocardiography shows left atrial enlargement.
Echocardiography shows moderate aortic regurgitation with an ejection fraction of 45%.
Which of the following tests is indicated to evaluate his murmur?
adenosine tracer stress testing
rapid plasma reagin
blood cultures
HIV serology
human leukocyte antigen (HLA) typing
5) You are following up with a man aged 65 years after he received treatment for hypertension.
His only complaint is shortness of breath with moderate to heavy exertion, but he tells you
that it does not occur at rest or when he is performing light activity. His medical history is
only notable for hypertension, for which he takes hydrochlorothiazide and metoprolol. He
does not smoke or drink alcohol. On examination, he has a 2/6 systolic murmur at the right
upper sternal border radiating to the carotids. Echocardiography shows mild left ventricular
hypertrophy, an ejection fraction of 55%, and a bicuspid aortic valve with aortic valve area
of
0.9 cm2. What is the appropriate management for his valve disease?
treadmill stress testing
digoxin
left heart catheterization with valvuloplasty
aortic valve replacement
beginning enalapril
6) A 35-year-old woman is seen for palpitations that occur a few times per week. She has no
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notable medical history, and her only medication is an oral contraceptive. She does not
smoke or drink alcohol. She works as a city garbage collector. Her vital signs are:
temperature 37.2 °C, heart rate 77 beats/minute and regular, blood pressure 115/75 mm Hg,
respiratory rate 18 breaths/minute, and oxygen saturation 99% on room air. On cardiac
examination, her heart rate is regular with a normal S1 and S2, a midsystolic click followed
by a late systolic murmur at the apex. During the straining phase of the Valsalva maneuver,
the click occurs earlier, and the murmur is more intense. Findings on electrocardiography are
normal. Holter monitor shows occasional premature ventricular contractions and premature
atrial contractions only. What is the most appropriate management in this patient's
condition?
nitroglycerin 0.4 mg sublingual as needed
digoxin
echocardiography
aspirin 500 mg per day
reassurance and low-dose metoprolol
7) A 45-year-old woman presents to you at the request of her dentist. The patient has a medical
history of mitral valve prolapse and takes no medications. She has no symptoms other than
tooth pain. She does not smoke or drink alcohol. She works as a city garbage collector. Her
vitals are: temperature 37.0 °C, heart rate 77 beats/minute and regular, blood pressure 115/75
mm Hg, respiratory rate 18 breaths/minute, and oxygen saturation 99% on room air.
Examination of the head, eyes, ear, nose, and throat, as well as lung, abdominal, and
neurologic examinations are normal. On cardiac examination, the rhythm is regular with a
normal S1 and S2, a midsystolic click followed by a late systolic murmur at the apex. With
squatting, the click and murmur occur later. Findings on electrocardiography are normal.
Transthoracic echocardiography shows thickened mitral valve leaflets that prolapse above
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