Common Valvular Heart Disease (at a glance)
Features /Points Mitral Stenosis Mitral Aortic Stenosis Aortic Regurgitation
Regurgitation
Peripheral Signs (Pulse) Low volume pulse, Normal Low volume slow High volume, Collapsing
normal in rhythm & Atrial rising pulse & Narrow pulse.
character or irregularly fibrillation/flutter pulse pressure Dancing Carotid pulse.
irregular (Atrial Quincke’s sign – Capillary
fibrillation) pulsation in nail beds.
Mitral facies (Malar de Musset’s sign – Head
flush) nodding with each pulse.
Duroziez’s sign – Pistol shot
murmur/bruit over femoral
artery.
Hills sign – Higher BP in legs
than arms.
Mueller’s sign – Pulsation in
uvula with heart beat.
Three BP – High systolic, Low
diastolic, Wide pulse pressure.
Palpation Apex Tapping Thrusting, active and Thrusting apex beat (LV Displaced, heaving apex beat
beat Others : RV heave, loud rocking (Volume pressure overload) (Volume overload)
P2 (pulmonary overload)
hypertension)
Thrill Diastolic apical thrill Systolic apical thrill Systolic apical thrill Diastolic apical thrill
Auscultation Heart Loud first heart sound Soft S1, apical S3 Soft second heart Fourth heart sound
sound and opening snap Sound 1st & 2nd heart sound normal
Murmur Low pitched, localized, Loud, blowing in Harsh, high pitched High pitch, blowing
rough, rumbling, character and musical Early diastolic murmur
Mid diastolic murmur Pansystolic murmur Ejection systolic Best heard in left lower para
Best heard with bell of Best heard at the apex murmur sternal area (3rd or 4th space)
stethoscope in left lateral that radiate to left Best heard in aortic with patient sitting and leaning
position and breathe hold axilla. area and radiate to right forward and breath hold after
after expiration. side of the neck. expiration.
Other murmur :
• Systolic murmur (increased
stroke volume)
• Austin Flint murmur (soft
mid-diastolic)
Symptoms • Breathlessness • Dyspnoea (pulmonary • Mild or moderate Mild to moderate aortic
• Fatigue venous congestion) stenosis: regurgitation
• Oedema, ascites • Fatigue (low cardiac usually asymptomatic • Often asymptomatic
• Palpitation output) • Exertional dyspnoea • Awareness of heart beat,
• Haemoptysis • Palpitation (atrial • Angina ‘palpitations’
• Cough fibrillation, increased • Exertional syncope Severe aortic regurgitation
• Chest pain stroke volume) • Sudden death • Breathlessness
• Thromboembolic • Oedema, ascites (right • Episodes of acute • Angina
complications (e.g. heart failure) pulmonary oedema
stroke, ischaemic limb)
Investigations ECG • Right ventricular • Left atrial hypertrophy • Left ventricular • Initially normal, later left
hypertrophy: tall R waves (if not in atrial hypertrophy (usually) ventricular hypertrophy and T-
in V1–V3 fibrillation) • Left bundle branch wave inversion
• P mitrale or atrial • Left ventricular block
fibrillation hypertrophy
Chest X- • Enlarged LA & • Enlarged LA • May be normal; • Cardiac dilatation, maybe
ray Appendage • Enlarged LV sometimes enlarged LV aortic dilatation
(Straightening of Lt • Pulmonary venous and dilated • Features of left heart failure
border of heart, Double congestion ascending aorta on PA
shadow in Rt border of • Pulmonary oedema (if view, calcified valve on
heart) acute) lateral view
• Signs of pulmonary
venous congestion
(Kerley B line, Widening
of carina)
