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• misattribution of the source of an aortic systolic murmur
  oscar,m jolobe
  Published on: 2 January 2019
• a role for point of care scanning in the emergency context
  oscar,m jolobe
  Published on: 1 January 2019

• Published on: 2 January 2019

  misattribution of the source of an aortic systolic murmur

  • oscar,m jolobe, retired geriatrician manchester medical society

  One of the potential benefits of point of care ultrasonography is that it might mitigate the risk of misattribution of the source of an aortic systolic murmur elicited by auscultation in patients who have clinically significant aortic stenosis(AS). When the murmur of AS is loudest at the cardiac apex there is a risk that it might be misattributed to mitral regurgitation(MR), especially in the presence of atrial fibrillation(AF)(1), given the fact that it is MR, rather than AS, which is a commoner cause of AF. The corollary is to attribute the murmur to severe anaemia(2)(when that murmur is elicited(by auscultation) in a patient who has iron deficiency anaemia attributable to chronic blood loss associated with Heyde's syndrome(3).
  Severe AS-associated hypertension(with systolic blood pressure up to nearly 200 mm Hg)(4) can also dominate clinical decision-making to the exclusion of a focus on AS. Diagnostic confusion is compounded by the fact that hypertension, in its own right, can be the underlying cause of a systolic murmur, sometimes even in the absence of post mortem evidence of calcification at the bases of the cups "nor any other abnormality"(5). The caveat is that, exceptionally, the association of hypertension and a systolic murmur(with suprasternal radiation) may be a late presentation of coarctation of the aorta(6). In the latter example echocardiography revealed a normal looking non-stenotic valve with mild regurgitation(6).
  Refer...

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  One of the potential benefits of point of care ultrasonography is that it might mitigate the risk of misattribution of the source of an aortic systolic murmur elicited by auscultation in patients who have clinically significant aortic stenosis(AS). When the murmur of AS is loudest at the cardiac apex there is a risk that it might be misattributed to mitral regurgitation(MR), especially in the presence of atrial fibrillation(AF)(1), given the fact that it is MR, rather than AS, which is a commoner cause of AF. The corollary is to attribute the murmur to severe anaemia(2)(when that murmur is elicited(by auscultation) in a patient who has iron deficiency anaemia attributable to chronic blood loss associated with Heyde's syndrome(3).
  Severe AS-associated hypertension(with systolic blood pressure up to nearly 200 mm Hg)(4) can also dominate clinical decision-making to the exclusion of a focus on AS. Diagnostic confusion is compounded by the fact that hypertension, in its own right, can be the underlying cause of a systolic murmur, sometimes even in the absence of post mortem evidence of calcification at the bases of the cups "nor any other abnormality"(5). The caveat is that, exceptionally, the association of hypertension and a systolic murmur(with suprasternal radiation) may be a late presentation of coarctation of the aorta(6). In the latter example echocardiography revealed a normal looking non-stenotic valve with mild regurgitation(6).
  References
  (1) Rispler S., Rinkevich D., Markiewicz ., Reisner SA
  Missed diagnosis of severe symptomatic aortic stenosis
  Am J Cardiol 1995;76:728-730
  (2) Varat MA., Adolph RJ., Fowler NO
  Cardiovascular effects of anemia
  Am Heart J 1972;83:415-426
  (3)Saad RA., Lwaleed BA., Kazmi RS
  Gastrointestinal bleeding and aortic stenosis(Heyde's syndrome): The role of aortic valve replacement
  J Card Surg 2013;28:414-416
  (4) Zezulka A., MacKinnon J., Beevers DG
  Hypertension in aortic valve disease and its response to valve replacement
  Postgrad Med J 1992;68:180-185
  (5) Barlow J., Kincaid-Smith P
  The auscultatory findings in hypertension
  Brit Heart J 1960;22:505-514
  (6) Ramcharan T., Taylor A., Chikemane A
  Hypertension and murmur with a "normal echo" An uncommon late presentation of coarctation of the aorta
  Heart 2016;102(Suppl 1):P33

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  Conflict of Interest:
  None declared.

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• Published on: 1 January 2019

  a role for point of care scanning in the emergency context

  • oscar,m jolobe, retired geriatrician manchester medical society

  Point of care scanning for heart murmurs should be made available, not only in heart murmur clinics, but also in the emergency context so as to expedite timely identification of murmurs attributable to cardiovascular disorders that require urgent interventional management . The following are some examples:-
  (i) Acute aortic or mitral valvular regurgitation. The former is typically attributable either to aortic dissection or to Infective endocarditis(IE), and the latter is typically attributable to papillary muscle rupture. In both contexts the murmur is typically soft or even clinically inaudible(1)(2), but timely surgical intervention is life-saving.
  (ii) Ischaemic cerebral infarct attributable to IE-related septic embolus. In some of these patients no murmur can be clinically detected(3). Nevertheless, identification of a murmur would raise the index of suspicion for IE.. If further evidence is obtained to support the diagnosis of IE, thrombolyis would be avoided because of the associated risk of haemorrhagic transformation of the septic crebral infract(3), and thrombectomy would be the safer strategy(4).
  References
  (1) Stout KK., Verrier ED
  Acute valvular regurgitation
  Circulation 2009;119:3232-3241
  (2) Hamirani YS., Dietl CA., Voyles V et al
  Acute aortic regurgitation
  Circulation 2012;126:1121-1126
  (3) Walker KA., Sampson JB., Skalabrin EJ., Majersik JJ
  Clinical characteristics and thrombolytic outc...

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  Point of care scanning for heart murmurs should be made available, not only in heart murmur clinics, but also in the emergency context so as to expedite timely identification of murmurs attributable to cardiovascular disorders that require urgent interventional management . The following are some examples:-
  (i) Acute aortic or mitral valvular regurgitation. The former is typically attributable either to aortic dissection or to Infective endocarditis(IE), and the latter is typically attributable to papillary muscle rupture. In both contexts the murmur is typically soft or even clinically inaudible(1)(2), but timely surgical intervention is life-saving.
  (ii) Ischaemic cerebral infarct attributable to IE-related septic embolus. In some of these patients no murmur can be clinically detected(3). Nevertheless, identification of a murmur would raise the index of suspicion for IE.. If further evidence is obtained to support the diagnosis of IE, thrombolyis would be avoided because of the associated risk of haemorrhagic transformation of the septic crebral infract(3), and thrombectomy would be the safer strategy(4).
  References
  (1) Stout KK., Verrier ED
  Acute valvular regurgitation
  Circulation 2009;119:3232-3241
  (2) Hamirani YS., Dietl CA., Voyles V et al
  Acute aortic regurgitation
  Circulation 2012;126:1121-1126
  (3) Walker KA., Sampson JB., Skalabrin EJ., Majersik JJ
  Clinical characteristics and thrombolytic outcomes of infective endocarditis-associated stroke
  Neurohospitalist 2012;2;87-91
  (4)Liang JJ., Bishu KG., Anavekar NS
  Infective endocarditis complicated by acute ischemic stroke from septic embolus: successful solitaire FR thrombectomy
  Cardiol Res 2012;3:277-280

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  Conflict of Interest:
  None declared.

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