Differentials
Mitral regurgitation (MR)
SIGNS / SYMPTOMS
Distinguishing signs are right ventricular heave, soft S1, split S2, and aloud P2. The classical murmur of MR is pansystolic at the apex radiating to the axilla.
INVESTIGATIONS
CXR: pulmonary oedema, enlarged left atrium and left ventricle, and mitral valve calcification.
ECG: can present with atrial fibrillation.
Echocardiography: for MR it is used to assess left ventricular function.
Mitral stenosis
SIGNS / SYMPTOMS
Distinguishing features are a malar flush, low volume pulse, a tapping and undisplaced apex beat, and loud S1 with an opening snap.
The murmur is a rumbling mid-diastolic one, which can be distinguished from the Austin Flint murmur sometimes heard in severe AR by the absence of the opening snap and loud S1.
INVESTIGATIONS
CXR: pulmonary oedema, enlarged left atrium, and mitral valve calcification.
ECG: can present with atrial fibrillation. Right ventricular hypertrophy may also be present.
Echocardiography: diagnostic for mitral stenosis.
Aortic stenosis
SIGNS / SYMPTOMS
Presentation includes dyspnoea, dizziness, fainting, and congestive cardiac failure.
Characteristic signs are a slow rising pulse, heaving but undisplaced apex bear, left ventricular heave, and an ejection systolic murmur that radiates towards the carotids and can have an ejection click. This can be distinguished from the ejection systolic murmur that is sometimes heard with moderate or severe AR by absence of an ejection click and no radiation towards the carotids.
INVESTIGATIONS
CXR: left ventricular hypertrophy (LVH), calcified aortic valve.
ECG: P-mitrale, LVH with strain pattern, left bundle branch block, or complete atrioventricular block.
Echocardiography: diagnostic for aortic stenosis.
Pulmonary regurgitation
SIGNS / SYMPTOMS
Diamond-shaped diastolic murmur best heard in the second and third left intercostal spaces. The murmur increases with inspiration, and P2 is loud in the presence of pulmonary artery hypertension.
INVESTIGATIONS
CXR: may show dilation of main pulmonary artery with right ventricular dilation.
ECG: right ventricular hypertrophy is usually present.
Echocardiography: diagnostic for pulmonary regurgitation.
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