Differentials
Acute coronary syndrome (ACS)
SIGNS / SYMPTOMS
There may be a history of angina or cardiovascular disease, relief of symptoms with rest or nitrates, and risk factors such as family history, smoking, diabetes mellitus, and hyperlipidemia.
The patient with ACS typically presents with central crushing chest pain lasting >20 minutes, often associated with nausea, sweatiness, dyspnea, and palpitations.
INVESTIGATIONS
ECG shows ST-segment elevation (in ACS with ST elevation) or depression (in ACS without ST elevation), tall or inverted T waves, or new left bundle branch block. Cardiac enzymes are elevated.
Infective endocarditis
SIGNS / SYMPTOMS
Typically presents with a new murmur, or change in the nature of an existing one, with fever, anemia, splenomegaly, or clubbing.
INVESTIGATIONS
Blood cultures are positive in infective endocarditis.
A CBC may show anemia, elevated neutrophils, and elevated erythrocyte sedimentation rate or CRP.
Echo shows vegetations if larger than 2 mm, giving a cause for a new murmur.
Mitral stenosis
SIGNS / SYMPTOMS
Presents with dyspnea, fatigue, palpitations, and chest pain.
Distinguishing features are a malar flush, a low volume pulse, a tapping and undisplaced apex beat, loud S1 with an opening snap.
The murmur is a rumbling mid-diastolic one, which can be distinguished from the Austin Flint murmur by the absence of the opening snap and loud S1.
INVESTIGATIONS
CXR: mitral stenosis may show pulmonary edema, but other features include enlarged left atrium and mitral valve calcification.
ECG: patients with mitral stenosis can present with atrial fibrillation. Right ventricular hypertrophy may be present, too.
Echo is diagnostic for mitral stenosis.
Aortic stenosis
SIGNS / SYMPTOMS
Presentation includes dyspnea, dizziness, fainting, and congestive cardiac failure.
Characteristic signs are a slow rising pulse, heaving but undisplaced apex beat, left ventricular heave, and an ejection systolic murmur that radiates toward the carotids and can have an ejection click.
INVESTIGATIONS
CXR: aortic stenosis may show left ventricular hypertrophy, but other features include a calcified aortic valve.
ECG: aortic stenosis may show P mitrale, left ventricular hypertrophy with strain pattern, left bundle branch block, or complete AV block.
Echo is diagnostic for aortic stenosis.
Aortic or pulmonic valve disease
SIGNS / SYMPTOMS
Aortic or pulmonic ejection clicks best heard to the right and left of the upper sternum, respectively. Click timing not affected by dynamic maneuvers.
INVESTIGATIONS
Echo is diagnostic for bicuspid aortic valve and pulmonic valvular disease.
Atrial myxoma
SIGNS / SYMPTOMS
May have symptoms of weight loss, fever, and malaise. Exam may reveal a diastolic tumor plop or diastolic murmur.
INVESTIGATIONS
Heterogeneous masses may be sessile, typically in left atrium. Transesophageal echo may yield more detail than transthoracic echo. Laboratory evaluation may reveal leukocytosis.
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