Q. Cardiology. A 46 year old lady comes to the floor. You are asked to be witness to her cardiac stress test with the technician. You have completed your ACLS certification.
She gets on the treadmill and starts to exercise. Her BP response, HR response and symptoms are stable as she proceeds. During the 5th minute on the Bruce protocol, she complains of feeling short of breath.
You auscultate her and notice a murmur that may be Mitral regurgitation.
She continues exercise and feels further shortness of breath. This makes you stop the test.
In the recovery phase she feels better in about 2 minutes and upon auscultation, she does not have any murmur.
Which of the following statements is true?
1. Ejection murmurs are common during exercise and should not lead to stoppage of the test in this case.
2. Ejection murmurs with shortness of breath indicate ischemic mitral regurgitation which is an indication to do cardiac cath.
3. The murmur is most likely functional
4. The murmur is most likely due to movement f the patient against the stethoscope
5. The murmur has no bearing on the next step in the patient's management.
The answer is 2.
"Objective","Recognize Exercise Induced Ischemic Mitral Regurgitation":
"The clinical presentation includes exertional breathlessness but signs of heart failure on examination are absent during rest.
In such cases, exercise treadmill testing reproduces the symptoms and auscultation during exercise reveals an apical systolic murmur that disappears during recovery.
Note that the EKG may be completely normal.
Such a finding represents significant obstructive coronary artery disease in a territory of the vascular supply of the papillary muscle and when rendered ischemic, results in mitral regurgitation due to inability of leaflet coaptation. Such patients should undergo cardiac catheterization since revascularization of the right coronary artery (or in some cases the left circumflex artery) might relieve the symptoms of exertional dyspnea."
Author: "Mandeep R. Mehra, MD"