ValvularHeartDisease

AS · MR · AR · MS · TR · intervention thresholds · TAVR vs SAVR · 2023 ACC/AHA guidelines · Super Compact

Aortic Stenosis (AS)

  • Sx: classic triad: angina (↓coronary reserve; average survival 5 yr) · syncope (↑LV-aorta gradient + peripheral vasodilation during exertion; average 3 yr) · dyspnea/HF (LV failure from afterload mismatch; average 1–2 yr); harsh crescendo-decrescendo systolic ejection murmur RUSB → carotids; pulsus parvus et tardus (slow-rising + small-volume carotid pulse — best bedside sign); S4 gallop (↓LV compliance from LVH); narrow PP (↓SV)

  • Neg: denies murmur radiating to axilla + holosystolic quality (MR — AS murmur peaks mid-systole + radiates to neck; MR is holosystolic to axilla) · denies immediate diastolic decrescendo murmur at LLSB without systolic murmur (AR — different valve; different physiology; wide PP vs narrow PP in AS) · denies murmur loudening with Valsalva release (HCM — HCM murmur increases during Valsalva straining [↓preload] and decreases with release; AS murmur unchanged with Valsalva)

  • Data: echo TTE (severe AS: AVA <1.0 cm2 [very severe <0.6]; mean gradient >40 mmHg; peak velocity >4.0 m/s; LVH; EF may be preserved until late — low-flow low-gradient AS: AVA<1+EF<50+gradient<40 → dobutamine [Dobutrex] stress echo to confirm true severe AS)

  • Intervention: AVR (TAVR or SAVR) — Class I if: severe AS + symptoms (angina/syncope/HF) OR severe AS + EF<50% OR severe AS undergoing other cardiac surgery; TAVR preferred if >65 or high/prohibitive surgical risk; SAVR if younger+bicuspid AoV+complex anatomy; DO NOT give hydralazine (Apresoline)/nitrates — ↓preload → hemodynamic collapse in preload-dependent AS

Mitral Regurgitation (MR)

  • Sx: chronic primary MR (MVP/chord rupture/RHD): exertional dyspnea · fatigue · AF · HF late; acute severe MR (papillary muscle rupture post-MI/chord rupture/endocarditis): sudden-onset pulmonary edema + cardiogenic shock; holosystolic murmur at apex radiating to axilla (primary) or LLSB (posterior leaflet) or neck (anterior leaflet); may be soft or absent in acute severe MR (rapid LV–LA equalization mutes murmur) | Soft or absent murmur in acute MR does NOT exclude severe disease — bedside echo mandatory

  • Neg: denies harsh mid-systolic crescendo-decrescendo murmur at RUSB radiating to neck without holosystolic character (AS — not MR; AS has pulsus parvus et tardus; MR has normal or wide PP and hyperdynamic apex) · denies new holosystolic murmur at LLSB with step-up in O2 saturation from RA to RV (VSD post-MI — VSD vs papillary rupture: VSD has left-to-right shunt + step-up; MR has no O2 step-up → echo urgently distinguishes)

  • Data: echo TTE+TEE (regurgitant volume; vena contracta >7 mm = severe; EROA >0.40 cm2 = severe primary MR; LA dilation; LV size+EF; mechanism: primary [leaflet/chord] vs secondary [LV dilation+annular])

  • Intervention: MV repair preferred over replacement; Class I if: severe primary MR + symptoms (NYHA II–IV) OR severe MR + EF<60% OR severe MR + LVESD >40 mm; transcatheter MV repair (MitraClip) if inoperable/high-risk primary MR or secondary MR with LVEF 20–50% on GDMT (COAPT 2018: ↓HF hosp 47%; ↓mortality 30%); acute severe MR (papillary rupture) → emergent surgery + IABP bridge

Aortic Regurgitation (AR)

  • Sx: chronic AR: exertional dyspnea · reduced exercise tolerance · palpitations (↑SV with wide PP); classic signs: wide pulse pressure (>60 mmHg; water-hammer/Corrigan pulse); diastolic decrescendo murmur at LLSB (lean forward+held exhalation); Austin Flint murmur (low rumble at apex = AR jet impinging on anterior mitral leaflet); acute severe AR (endocarditis/dissection): sudden APE + cardiogenic shock; murmur may be short+soft (rapid LV–aorta pressure equalization)

  • Neg: denies narrow pulse pressure + harsh systolic murmur at RUSB without wide PP (AS — AS has narrow PP+slow-rising carotid; AR has wide PP+water-hammer carotid; do not confuse these two aortic valve diseases) · denies early opening snap + mid-diastolic rumble at apex (MS — MS has narrow PP+opening snap; AR has wide PP+decrescendo diastolic murmur)

  • Data: echo TTE (holodiastolic flow reversal in descending aorta = severe AR; vena contracta >6 mm = severe; LVESD >50 mm or LVEDD >65 mm = surgical thresholds; EF — LV function; aortic root diameter)

  • Intervention: AVR Class I if: severe AR + symptoms OR severe AR + EF<55% OR severe AR + LVESD >50 mm; vasodilators (nifedipine [Procardia] or hydralazine [Apresoline]) only for symptom palliation if surgery not yet; acute severe AR → emergent AVR + vasodilators bridge (avoid IABP — diastolic balloon inflation worsens AR); BB reduce diastolic filling time → ↓preload — use cautiously

Mitral Stenosis (MS)

  • Sx: exertional dyspnea → orthopnea → APE; AF (LA dilation — mandatory anticoag regardless of CHA2DS2-VASc; loss of atrial kick → hemodynamic crisis); hemoptysis (pulmonary venous HTN → alveolar hemorrhage); hoarseness (Ortner syndrome — enlarged LA compressing left recurrent laryngeal nerve); opening snap followed immediately by low-pitched mid-diastolic rumble at apex (bell; left lateral decubitus; increases with exhalation); loud S1

  • Neg: denies wide pulse pressure + decrescendo early diastolic murmur without opening snap (AR — not MS; MS has narrow PP + opening snap; AR has wide PP + no snap) · denies murmur that decreases with inspiration (all left-sided murmurs decrease with inspiration; right-sided murmurs increase — Carvallo sign) · denies AF without mandatory anticoagulation (MS+AF = highest stroke risk of any cardiac valve disease; anticoag mandatory regardless of CHA2DS2-VASc score — rheumatic MS is the one exception to CHA2DS2-VASc guidelines)

  • Data: echo TTE (MVA by PHT [pressure half-time]: normal >4 cm2; mild 1.5–4; moderate 1.0–1.5; severe <1.0 cm2 [critical <0.6]; mean gradient >10 mmHg at rest = significant; Wilkins score [mobility+subvalvular thickening+calcification+leaflet thickening 1–4 each; ≤8 = favorable for PBMV]; LA size; TR velocity [pulm HTN from MS])

  • Intervention: PBMV (percutaneous balloon mitral valvotomy) Class I if: symptomatic severe MS (MVA <1.5 cm2) + Wilkins ≤8 + no significant MR + no LAA thrombus; MVR (mitral valve replacement) if PBMV not feasible; anticoag (warfarin [Coumadin] INR 2–3 mandatory for MS+AF — DOACs NOT approved for rheumatic MS+AF in landmark trials)

Tricuspid Regurgitation (TR)

  • Sx: mostly asymptomatic until severe; RHF signs: JVD · pulsatile hepatomegaly · ascites · bilateral edema; pulsatile neck veins with prominent v-wave; holosystolic murmur at LLSB increasing with inspiration (Carvallo sign — distinguishes right-sided from left-sided)

  • Neg: denies holosystolic murmur at LLSB decreasing with inspiration (left-sided murmurs [MR/VSD] decrease with inspiration; TR increases with inspiration — Carvallo sign is the bedside differentiator) · denies symptoms of left heart failure (pulmonary edema/orthopnea) as primary finding — TR causes right heart failure symptoms

  • Intervention: usually secondary to left heart disease or pulm HTN — treat primary cause first; TV repair at time of other cardiac surgery if severe functional TR; isolated tricuspid intervention if severe primary TR with progressive RV dilation + symptoms (transcatheter tricuspid repair/replacement emerging)

Plan — General Valvular Principles

  • All admitted valvular disease patients: echo TTE (confirm + quantify); cardiology consult; anticoag: all MS+AF → warfarin (Coumadin) INR 2–3 (DOACs not approved for rheumatic MS+AF); mechanical valve → warfarin (Coumadin) INR per valve type (mechanical aortic: 2–3; mechanical mitral: 2.5–3.5); bioprosthetic valve → aspirin (Bayer) 81 mg PO daily ×3–6 months post-implant (then aspirin alone if sinus rhythm); all valvular disease patients: IE prophylaxis education (amoxicillin [Amoxil] 2 g PO 30–60 min before dental/surgical procedures)

  • Acute severe MR (papillary muscle rupture/chord rupture/endocarditis): emergent cardiothoracic surgery consult; IABP bridge (↓afterload → ↓regurgitant volume; ↑forward CO); nitroglycerin (NTG) IV 5–200 mcg/min (↓preload + afterload → ↓pulmonary congestion); avoid IABP in AR (↑regurgitation during balloon deflation)

  • Acute severe AR (endocarditis/dissection): emergent AVR; nitroglycerin (NTG) IV (↓preload) + vasodilator (nicardipine [Cardene] or sodium nitroprusside [Nipride]); avoid IABP (↑AR); BB contraindicated (bradycardia → ↑diastolic filling time → ↓forward CO)

  • Severe AS management: avoid nitrates/hydralazine (Apresoline) — preload reduction → hemodynamic collapse in AS (preload-dependent); gentle diuresis only if congested (furosemide [Lasix] 20–40 mg IV); maintain sinus rhythm (AF poorly tolerated — cardiovert); definitive: TAVR or SAVR based on age+anatomy+risk score

  • MS with decompensation: diuresis (furosemide [Lasix] 40–80 mg IV); rate control (HR 60–70 bpm — slows filling time → more LA emptying); metoprolol tartrate (Lopressor) 2.5–5 mg IV if AF-RVR; avoid tachycardia; anticoag if AF (warfarin [Coumadin]); TEE before cardioversion (LAA thrombus common in MS)

  • HF from valvular disease: GDMT (Entresto+Coreg+Aldactone+Farxiga) for secondary MR (functional MR from LV dilation) — GDMT ↓mitral annular dilation → ↓MR severity; GDMT does NOT change natural history of primary MR (leaflet disease); GDMT for AR (vasodilators); NO proven medical therapy for AS — surgery/TAVR only

  • PT/OT — activity restriction based on severity and symptoms; cardiac rehab post-valve intervention; fall risk assessment (anticoag); pre-surgery functional status

  • Trend: echo annually (mild-moderate disease; sooner if symptoms change) · BMP (Cr/K+ — diuretics; ACEi/ARB monitoring) · INR weekly until stable then monthly (warfarin [Coumadin]) · troponin if acute decompensation · fever curve (endocarditis concern with any new fever + valve disease)

  • Discharge: valve disease education; activity limitations per severity; IE prophylaxis (amoxicillin [Amoxil] 2 g PO or clindamycin [Cleocin] 600 mg PO if PCN-allergic); anticoag plan (warfarin [Coumadin] for MS+AF + mechanical valves; aspirin [Bayer] 81 mg for bioprosthetic); follow-up echo per surveillance schedule; cardiology 2–4 weeks; cardiac surgery consultation if intervention criteria met

ValvularHeartDisease

AS · MR · AR · MS · TR · 2023 ACC/AHA guidelines · intervention thresholds · TAVR/SAVR · Full Card

Aortic Stenosis (AS) — Full

Sx / Exam

  • Classic triad: angina (average 5-year survival after symptom onset), syncope (average 3-year survival — exertional peripheral vasodilation with fixed CO → cerebral hypoperfusion), dyspnea/HF (average 1–2-year survival — worst prognosis of the three)

  • Murmur: harsh crescendo-decrescendo systolic ejection murmur; best at RUSB (2nd right ICS); radiates to carotid arteries and neck; peaks in mid-to-late systole (severe); often transmitted to apex (Gallavardin phenomenon) mimicking MR

  • Pulsus parvus et tardus (slow-rising + small-volume + delayed carotid upstroke — best bedside finding for severe AS); diminished A2 (aortic component of S2); S4 gallop (↓LV compliance from LVH); paradoxical split S2 in severe AS

  • Valsalva maneuver: AS murmur unchanged or slightly decreased (fixed obstruction); HCM murmur increases during straining phase (↓preload)

Neg

  • Pt denies holosystolic murmur radiating to the axilla that begins with S1 — argues against MR (AS is a systolic ejection murmur with diamond shape peaking mid-systole; MR is holosystolic [S1-to-S2] and radiates to axilla; AS murmur radiates to neck; MR has hyperdynamic apex and wide PP; AS has slow-rising carotid and narrow PP)

  • Pt denies decrescendo early diastolic murmur immediately following A2 at LLSB — argues against AR as the primary diagnosis (AR: wide pulse pressure + water-hammer carotid + early diastolic decrescendo murmur; AS: narrow pulse pressure + slow-rising carotid + systolic murmur; these are distinguishable with careful exam)

  • Pt denies increase in murmur intensity during Valsalva straining phase — argues against HCM (HCM murmur increases with ↓preload during Valsalva straining; AS murmur decreases or is unchanged; this bedside maneuver is the key clinical differentiator)

Data / Thresholds

  • Echo TTE: severe AS = AVA <1.0 cm2 (very severe <0.6 cm2) + peak velocity >4.0 m/s + mean gradient >40 mmHg; LVH; EF preserved until late decompensation; low-flow low-gradient AS (paradoxical): AVA <1.0 + EF ≥50% + mean gradient <40 — likely due to flow limitation; dobutamine (Dobutrex) stress echo (20 mcg/kg/min) if EF <50%: contractile reserve (↑CO >20%) + ↑gradient confirms true severe AS; absence of reserve = poor surgical candidate

  • CT calcium scoring of aortic valve: AVC >2000 AU men / >1200 AU women = severe AS (particularly useful when echo inconclusive)

  • Cardiac catheterization: only when echo inconclusive or coronary angiography needed pre-TAVR/SAVR

Intervention Thresholds (2023 ACC/AHA)

  • Class I AVR: severe AS + symptoms (SAV I + angina/syncope/HF = surgery regardless of EF); severe AS + EF <50% (even asymptomatic); severe AS undergoing other cardiac surgery

  • Class IIa AVR: very severe AS (peak velocity ≥5 m/s) + low surgical risk even if asymptomatic; severe AS with rapid progression (↑velocity ≥0.3 m/s/year)

  • TAVR vs SAVR: TAVR preferred if age >65 or high/prohibitive surgical risk (PARTNER trials); SAVR preferred if age <65, bicuspid AoV (asymmetric anatomy), concomitant CABG needed, endocarditis, complex root anatomy; TAVR expanding to younger/lower risk patients (PARTNER 3, EVOLUT Low-Risk trials)

Mitral Regurgitation (MR) — Full

Sx / Exam / Classification

  • Primary MR (leaflet/chord disease — MVP, myxomatous degeneration, chord rupture, endocarditis, RHD): holosystolic murmur at apex radiating to axilla; hyperdynamic LV apex (↑preload from regurgitation); soft S1; wide PP; chronic → LA dilation → AF

  • Secondary/functional MR (LV dilation → annular dilation + papillary displacement): murmur may be less intense; same quality as primary; treated with GDMT first (↓LV size → ↓annular dilation → ↓MR severity); MitraClip if persistent severe secondary MR on GDMT

  • Acute severe MR (papillary muscle rupture post-MI/chord rupture/endocarditis): sudden severe dyspnea + APE + cardiogenic shock; murmur may be soft or absent (rapid LV–LA pressure equalization); always obtain bedside echo in unexplained post-MI shock

Neg

  • Pt denies a harsh mid-systolic crescendo-decrescendo murmur at RUSB radiating to the neck with pulsus parvus et tardus — argues against AS as the diagnosis (MR: holosystolic + apex + axilla radiation + hyperdynamic apex + normal or wide PP; AS: systolic ejection + RUSB + carotid radiation + slow-rising carotid + narrow PP)

  • Pt denies new holosystolic harsh murmur at the LLSB with a step-up in oxygen saturation from the RA to RV on Swan-Ganz — argues against post-MI VSD (VSD: left-to-right shunt → step-up in O2 saturation at RV level; MR: no O2 step-up; echo distinguishes immediately — systolic flow jet at IVS = VSD; color Doppler across mitral valve = MR)

Intervention Thresholds (2023 ACC/AHA)

  • Primary MR Class I surgery: severe primary MR + symptoms (NYHA II–IV); severe primary MR + EF ≤60% or LVESD ≥40 mm (even asymptomatic); MV repair strongly preferred over replacement (↓mortality, ↓endocarditis, preserved LV function, no anticoag needed); repair rate >95% at expert centers

  • Transcatheter MV repair (MitraClip): inoperable/high-risk primary MR; secondary MR with LVEF 20–50% on optimal GDMT + symptoms (COAPT 2018, NEJM: ↓HF hospitalization 47% at 2 years; ↓all-cause mortality 30%; NNT for mortality ~4 over 2 years)

  • Acute severe primary MR (papillary muscle rupture): IABP (Datascope) or Impella CP (Abiomed) bridge → emergent MV repair/replacement; delay increases mortality significantly

Aortic Regurgitation (AR) — Full

Sx / Exam

  • Wide pulse pressure (>60 mmHg — water-hammer/Corrigan pulse; most specific exam finding); Quincke pulse (capillary pulsation in nail beds); de Musset sign (head bobbing with pulse); diastolic decrescendo murmur at LLSB (best with patient leaning forward + held exhalation); Austin Flint murmur (mid-diastolic rumble at apex — AR jet impinges on anterior mitral leaflet creating functional MS); displaced hyperdynamic LV apex

  • Acute severe AR (endocarditis/Type A dissection): sudden APE + cardiogenic shock; murmur may be short/soft (rapid LV–aorta pressure equalization limits diastolic flow time); S1 may be reduced (early mitral valve closure from rapid ↑LVEDP)

Neg

  • Pt denies narrow pulse pressure + slow-rising small-volume carotid pulse + systolic murmur at RUSB — argues against AS (AR has wide PP + hyperdynamic carotid; AS has narrow PP + slow-rising carotid — opposite exam findings at carotid)

  • Pt denies opening snap immediately following S2 with low-frequency mid-diastolic rumble — argues against MS (MS: narrow PP + opening snap + low rumble at apex increasing toward S1; AR: wide PP + no opening snap + decrescendo early diastolic murmur)

Intervention Thresholds (2023 ACC/AHA)

  • Class I AVR: severe AR + symptoms; severe AR + EF <55%; severe AR undergoing other cardiac surgery

  • Class IIa AVR: severe AR + EF 55–60% or LVESD >50 mm or LVEDD >65 mm (progressive LV dilation); aortic root >5.5 cm (or >5.0 cm in Marfan, Loeys-Dietz)

  • Acute severe AR: emergent AVR; bridge with vasodilators (nicardipine [Cardene]/nitroprusside [Nipride]); AVOID IABP (balloon inflation increases AR); AVOID BB (bradycardia → ↑diastolic filling time → ↑regurgitant volume → acute decompensation)

Mitral Stenosis (MS) — Full

Sx / Exam

  • Opening snap (high-pitched; earlier OS = more severe MS = higher LA pressure → earlier pressure crossover); low-pitched mid-diastolic rumble at apex with presystolic accentuation (if sinus rhythm); loud S1 (pliable valve leaflets snapping shut); shorter S2-OS interval = more severe MS (higher LA pressure)

  • AF: LA dilation → AF in ~40% of severe MS; loss of atrial kick + AF-RVR → acute decompensation; anticoag mandatory in ALL MS+AF (warfarin [Coumadin] INR 2–3; DOACs NOT approved for rheumatic MS+AF per pivotal trial enrollment criteria)

  • Pulmonary manifestations: hemoptysis (pulmonary venous HTN → alveolar hemorrhage from bronchopulmonary anastomoses); recurrent pulmonary infections; Ortner syndrome (hoarseness — enlarged LA compresses left recurrent laryngeal nerve)

Neg

  • Pt denies wide pulse pressure + decrescendo early diastolic murmur without an opening snap — argues against AR (AR: wide PP + no opening snap + early diastolic decrescendo; MS: narrow PP + opening snap + mid-diastolic low rumble; both have diastolic murmurs but entirely different characters and timing)

  • Pt denies AF associated with valvular disease without mandatory anticoagulation — rheumatic MS + AF is the one situation where anticoagulation is mandatory regardless of CHA2DS2-VASc score (score of 0 = still anticoag if MS+AF; warfarin [Coumadin] preferred over DOACs)

Intervention Thresholds (2023 ACC/AHA)

  • PBMV (percutaneous balloon mitral valvotomy) Class I: symptomatic severe MS (MVA <1.5 cm2) + Wilkins score ≤8 + no significant MR + no LAA thrombus on TEE; technically curative in favorable anatomy — commissure splitting → ↑MVA; ↓LA pressure → ↓AF → ↓stroke

  • MVR (mitral valve replacement) if: PBMV not feasible (Wilkins >8, significant MR, LAA thrombus); symptomatic severe MS + unfavorable anatomy; mechanical MVR preferred in younger patients (higher durability; warfarin [Coumadin] required INR 2.5–3.5)

  • Medical: diuretics for symptom relief; rate control (HR 60–70 bpm — slower HR allows more diastolic filling time across stenotic valve); warfarin (Coumadin) INR 2–3 for all MS+AF; anticoag also for MS+prior thromboembolism or very large LA (>55 mm) even in sinus rhythm

DDx — Valvular Disease

AS vs HCM (HCM murmur increases with Valsalva straining [↓preload]; AS unchanged/↓; HCM also increases with standing; both at LLSB-RUSB) · Primary MR vs secondary MR (primary: leaflet/chord pathology; GDMT does not fix; surgery/MitraClip; secondary: LV dilation → annular → optimize GDMT first) · Chronic AR vs acute severe AR (acute: short soft murmur + APE + shock; chronic: wide PP + long murmur + hyperdynamic LV) · MS vs Austin Flint (AR) (Austin Flint: AR jet on anterior MV = functional MS murmur; no opening snap; wide PP; treat AR not MS) · VSD vs MR post-MI (VSD: O2 step-up RA→RV; holosystolic LLSB + biventricular failure; MR: no step-up; echo definitively distinguishes)

General Management Principles

  • Echo surveillance schedule: severe AS: every 6–12 months (+ exercise stress test if asymptomatic); moderate AS: every 1–2 years; mild AS: every 3–5 years; severe MR: every 6–12 months; severe AR: every 6–12 months; severe MS: every 1 year; any new symptoms → echo immediately regardless of surveillance schedule

  • Anticoagulation: mechanical aortic valve → warfarin (Coumadin) INR 2–3 (+ aspirin [Bayer] 75–100 mg if low bleed risk); mechanical mitral valve → warfarin (Coumadin) INR 2.5–3.5 (+ aspirin [Bayer]); rheumatic MS + AF → warfarin (Coumadin) INR 2–3 (DOACs not approved for rheumatic MS+AF); bioprosthetic valve → aspirin (Bayer) 81 mg PO daily ×3–6 months post-implant; valvular AF (non-rheumatic) → DOACs per CHA2DS2-VASc

  • IE prophylaxis (AHA 2021 guidelines — Class IIa for high-risk procedures): amoxicillin (Amoxil) 2 g PO 30–60 min before dental procedures involving gingival manipulation or respiratory tract mucosal procedures; OR clindamycin (Cleocin) 600 mg PO if PCN-allergic; HIGH-RISK patients (prophylaxis indicated): prior IE, prosthetic valve or valvular repair material, complex congenital HD (cyanotic, post-repair with residual defect), cardiac transplant with valvulopathy

  • TAVR post-procedure management (first 30 days): aspirin (Bayer) 81 mg PO daily + clopidogrel (Plavix) 75 mg PO daily ×3 months → aspirin (Bayer) alone indefinitely (GALILEO trial: rivaroxaban [Xarelto] post-TAVR inferior to antiplatelet — more bleeding, more thrombosis); if AF → DOAC per CHA2DS2-VASc; new LBBB post-TAVR: monitor 48–72h for complete AV block → may need PM if persists

  • Warfarin (Coumadin) bridge for valve patients: mechanical valve patients requiring interruption for surgery: bridge with UFH if high-risk (mitral mechanical valve or aortic mechanical valve + AF/prior stroke/EF <35%); no bridge if low-risk aortic mechanical valve in sinus rhythm (BRIDGE trial — low VTE without bridging in non-valve patients; high-risk valves different)

⚠ Red Flags

  • Nitrates or hydralazine (Apresoline) in severe AS → preload reduction → ↓LV filling across fixed obstruction → ↓CO → hemodynamic collapse; AS patients are extremely preload-dependent; avoid all preload-reducing agents; gentle diuresis only with careful monitoring

  • Acute severe MR (papillary muscle rupture post-MI Days 3–7) — murmur may be soft or absent (rapid LV–LA pressure equalization mutes murmur velocity); every new systolic murmur post-MI = emergency bedside echo; diagnosis by echo color Doppler; IABP bridge + emergent surgery

  • IABP in acute severe AR → balloon inflation during diastole ↑aortic diastolic pressure → ↑regurgitant volume → worsen acute AR; NEVER use IABP in hemodynamically unstable AR; vasodilators (nitroprusside [Nipride]) + emergent AVR

  • BB in acute severe AR → ↓HR → ↑diastolic filling time → ↑regurgitant volume → ↑LVEDP → acute decompensation; BB are contraindicated in acute severe AR

  • DOACs for rheumatic MS + AF → DOACs were not tested in landmark trials for rheumatic MS; INVICTUS 2022 (rivaroxaban [Xarelto] vs warfarin [Coumadin] in rheumatic heart disease + AF) → rivaroxaban INFERIOR to warfarin (↑stroke + ↑CV death); warfarin (Coumadin) INR 2–3 is mandatory for rheumatic MS + AF

  • Stopping anticoag in mechanical valve without bridging → thrombosis of prosthetic valve → catastrophic stroke; mechanical valves require lifelong warfarin (Coumadin) without gaps; if urgent surgery required → bridge with UFH (never gap more than 24h for high-risk valves)

Senior IM Resident Pearls

  • The Classic AS Triad survival data: angina after symptom onset → average 5-year survival; syncope → average 3-year survival; dyspnea/HF → average 1–2-year survival; these numbers justify urgent referral for AVR in symptomatic severe AS; once symptoms develop, medical management alone is inadequate — surgery/TAVR is the treatment

  • Pulsus parvus et tardus — the best bedside sign for severe AS: slow-rising (tardus) + small-volume (parvus) carotid upstroke; place finger on carotid while auscultating — you can feel the delay; correlates with peak gradient >40 mmHg; the absence of a brisk carotid upstroke in a patient with a systolic murmur makes severe AS more likely

  • COAPT trial (2018, NEJM) — MitraClip in secondary MR: transcatheter mitral repair (MitraClip) vs optimal GDMT alone in symptomatic severe secondary MR (EF 20–50%) → ↓HF hospitalization 47% (NNT ~3 for hospitalization); ↓all-cause mortality 30% at 2 years; Class IIa for patients who remain symptomatic on optimal GDMT; GDMT must be optimized first — do not refer for MitraClip before maximizing Entresto+Coreg+Aldactone+Farxiga

  • INVICTUS 2022 (NEJM) — DOACs vs warfarin in rheumatic MS + AF: rivaroxaban (Xarelto) vs warfarin (Coumadin) in rheumatic heart disease + AF → rivaroxaban inferior (↑stroke [3.4% vs 2.0%] + ↑CV death); warfarin (Coumadin) INR 2–3 remains mandatory for rheumatic MS + AF; this is a critically tested clinical distinction — DOACs are NOT approved for this indication

  • Acute severe AR — 3 things NOT to do: (1) do NOT give IABP (↑AR during diastolic augmentation); (2) do NOT give BB (↓HR → ↑regurgitant volume → acute decompensation); (3) do NOT delay AVR — acute severe AR (endocarditis/dissection) with cardiogenic shock has very high in-hospital mortality without emergent surgery

  • Common mistake — ascribing all diastolic murmurs to AR: Austin Flint murmur (functional MS in AR) mimics true MS; differentiators: Austin Flint has NO opening snap (crisp high-pitched click) + has wide PP + concurrent AR murmur; treat AR, not MS; ordering PBMV for Austin Flint murmur is a dangerous error