WBR0439
| Author | [[PageAuthor::Yazan Daaboul, M.D. (Reviewed by Alison Leibowitz) (Reviewed by Serge Korjian)]] |
|---|---|
| Exam Type | ExamType::USMLE Step 1 |
| Main Category | MainCategory::Pathology |
| Sub Category | SubCategory::Cardiology |
| Prompt | [[Prompt::A 62-year-old woman presents to the physician’s office for multiple syncopal episodes. The patient reports that she has not been feeling well lately and is fatigued. She denies other associated symptoms or use of any medication. On cardiac auscultation, the physician hears a systolic crescendo-decrescendo murmur with ejection click best heard at the right second intercostal space and radiating to both carotids. Which of the following findings is most likely not associated with severity of the patient’s murmur?]] |
| Answer A | AnswerA::Time for murmur to peak |
| Answer A Explanation | AnswerAExp::The amount of time it takes for the murmur to peak correlates with the severity of AS. |
| Answer B | AnswerB::Intensity of the murmur |
| Answer B Explanation | AnswerBExp::The intensity of murmur does not correlate with AS severity. |
| Answer C | AnswerC::Onset of symptoms |
| Answer C Explanation | AnswerCExp::The onset of symptoms correlates with AS severity and is an indication for surgical intervention. |
| Answer D | AnswerD::Presence of left ventricular (LV) hypertrophy |
| Answer D Explanation | AnswerDExp::Presence of LV hypertrophy correlates with AS severity. |
| Answer E | AnswerE::Aortic valve area |
| Answer E Explanation | AnswerEExp::Aortic valve area, measured by Doppler echocardiography, is directly related to the severity of AS. |
| Right Answer | RightAnswer::B |
| Explanation | [[Explanation::Aortic stenosis (AS) is the most common valvulopathy in the Western world. AS is characterized by a triad of symptoms: syncope, angina, and dyspnea. On physical examination, AS is a systolic crescendo-decrescendo murmur with an ejection click that is best heard at the right sternal border, or the “aortic site”. AS murmur typically radiates to the carotids. The severity of AS murmur is associated with several findings regarding history, physical exam, and work-up. The manifestation of symptoms is associated with severity. Surgery is indicated as soon as symptoms develop, because average survival is less than 5 years after development of symptoms.
Hypertrophy is considered an adaptive response of the valvular disease. When the compliance of the left ventricle is reduced, the LV diastolic pressure (LVDP) increases and the LV wall thickens to cause decreased coronary artery blood flow and coronary flow reserve, manifesting in chest pain.
As AS becomes more severe, the duration of the murmur increases and peaks at mid to late systole. Early peak correlates with less severe stenosis, while late peak correlates with AS. The intensity of the murmur does not correlate with severity of disease. Finally, patients with AS have aortic valve thickening with reduced aortic valve area. Doppler echocardiography is an appropriate test to evaluate severity of AS by measuring jet velocity and gradients, as well as calculating aortic valve area. |
| Approved | Approved::Yes |
| Keyword | WBRKeyword::Aortic stenosis, WBRKeyword::AS, WBRKeyword::Cardiology, WBRKeyword::Cardiovascular system, WBRKeyword::Valvulopathy, WBRKeyword::Murmur |
| Linked Question | Linked:: |
| Order in Linked Questions | LinkedOrder:: |