Clinical features of valvular heart disease

An 82-year-old female is awaiting a hip hemiarthroplasty having sustained a fractured

neck of femur. She has mild dementia and is unable to relate her medical history. Her old notes are currently unavailable and as she has recently moved from out of the region her computer records are unhelpful. On examination she has a small volume, regular pulse. Her blood pressure is 136/72mmHg and her JVP is not raised. She has an undisplaced, tapping apex beat. On auscultation, she has a short rumbling diastolic murmur audible all over the praecordium. Which one of the following is the MOST LIKELY valve lesion?

a) Mitral stenosis

b) Aortic regurgitation

c) Mixed aortic valve disease

d) Tricuspid stenosis

e) Pulmonary regurgitation

Answer: a

Explanation

This is most likely to be a mild form of mitral stenosis, as if the severity increased the  features are so florid as to present no doubt as to the valve lesion in question. Each of these valve lesions may cause a diastolic murmur, so this case needs to be distinguished via its other clinical features. Mitral stenosis tends to be associated with atrial fibrillation, but in mild forms of the condition sinus rhythm is preserved. The small volume pulse and normal pulse pressure eliminates aortic regurgitation in which a wider pulse pressure and collapsing pulse is expected. Aortic stenosis in mixed aortic valve disease might give a small volume pulse as described, but then a systolic component to the murmur would be heard. The palpable first heart sound and ‘opening snap’ that gives the tapping apex beat is characteristic of mitral stenosis and not present in pulmonary valve regurgitation. Tricuspid stenosis shares many clinical features withmitral stenosis. If sinus rhythm is preserved, prominent jugular venous ‘a’ waves will be observed. It might be a contender for the answer here except that it is far less common than mitral stenosis so the ‘most likely valve lesion’ is still mitral stenosis.

Reference

Camm A. Cardiovascular disease. In: Kumar P, Clark M (eds) Clinical Medicine, 4th

edn. Edinburgh: W.B.Saunders, 1998; pp. 700–10.