A 24 year old car salesman presents to the office with a complaint of occasional shortness of breath. It happens whenever he exerts himself. He says that after climbing a flight of stairs, he has to rest and then he can start again after a couple of minutes. He has no palpitations. Has not had any loss of consciousness or coughing. No fever or rashes.

On examination, he has a systolic murmur at the apex. There is no thrill. The murmur decreases on hand grip and increases on valsalva.

Which of the following conditions is most likely?

HOCM

AS

MVP

VSD

MR without MVP

Answer is HOCM. Whenever a murmur increases with Valsalva, think HOCM and MVP. Valsalva decreases ventricular filling and leads to a narrower HOCM outlet. It also allows more laxity in the chordae tendinae due to less ventricular filling. This allows the prolapse to become more prominent.

Hand grip increases peripheral resistance. This decreases flow across aortic valve but puts more back pressure on mitral so AS & HOCM decrease but MR & MVP worsen.

See the table below too.

Q. Now if in the same patient, the murmur increased with Valsalva but also increased with Hand grip,

Which of the following conditions is most likely?

HOCM

AS

MVP with MR

VSD

MR without MVP

Answer is MVP with MR

Whenever a murmur increases with Valsalva, think HOCM and MVP. Valsalva decreases ventricular filling and leads to smaller LV and thus a narrower HOCM outlet. It also allows more laxity in the chordae tendinae due to less ventricular filling. This allows the prolapse to become more prominent. With less volume in ventricle to be ejected, the flow across the AS is less so it softens. Backflow in MR without MVP is less so it softens.

Hand grip increases peripheral resistance. This decreases flow across aortic valve but puts more back pressure on mitral so AS & HOCM decrease but MR & MVP worsen.

Q. Now if the murmur decreased with Valsalva and increased with Hand grip,

Which of the following conditions is most likely?

HOCM

AS

MVP

VSD

MR without MVP

Answer is MR without MVP

CARDIOLOGY

Distinguish various causes of a long systolic murmur at the apex.

Explanation:

Long systolic murmurs can be heard because of one of three lesions mainly.

MR. VSD or moderate or severe AS.

MR and AS can be best heard at the apex whereas VSD is best heard at the sternal border and is most likely to be associated with a thrill.

MR loudens into the axilla and also with hand grip. AS on the other hand softens with both. A heaving apex goes with AS and a hyperdynamic impulse goes with MR or VSD.