A 68-year-old man comes to the emergency department because of a 1-week history of difficulty breathing. He has had recurrent palpitations over the past 2 years. During this time, he has also had several episodes of anxiety despite no change in his daily life. He has occasional sharp chest pain localized to the left upper sternal border. He has no abdominal pain or leg swelling. Two years ago, he had streptococcal pharyngitis, which was promptly treated with a 10-day course of penicillin. He has never traveled outside of the country. His temperature is 36.5°C (97.7°F), pulse is 82/min, and blood pressure is 140/85 mm Hg. Physical examination shows a 3/6 holosystolic murmur that is loudest at the apex and radiates to the axilla with a mid-systolic click. Bilateral fine crackles are heard on lung auscultation. Which of the following is the most likely cause of this patient's symptoms?

Inflammatory valve degeneration

Ectopic production of serotonin

Overproduction of catecholamines

A 27-year-old woman with a history of a "heart murmur since childhood" presents following a series of syncopal episodes over the past several months. She also complains of worsening fatigue over this time period, and notes that her lips have begun to take on a bluish tinge, for which she has been using a brighter shade of lipstick. You do a careful examination, and detect a right ventricular heave, clubbing of the fingers, and 2+ pitting edema bilaterally to the shins. Despite your patient insisting that every doctor she has ever seen has commented on her murmur, you do not hear one. Transthoracic echocardiography would most likely detect which of the following?

Dynamic left ventricular outflow tract obstruction

A 72-year-old man who was involved in a traffic collision is brought to the emergency room by the ambulance service. He was in shock and comatose at the time of presentation. On examination, the heart rate is 60/min, and the blood pressure is 70/40 mm Hg. The patient dies, despite resuscitative efforts. Autopsy reveals multiple internal hemorrhages and other evidence of ischemic damage affecting the lungs, kidneys, and brain. The patient’s heart shows evidence of gross anomaly similar to the picture. While acute hypovolemia is the likely cause of the ischemic changes seen in the lungs, kidneys, and brain, which of the following best explains the gross anomaly of his heart?

Senile calcific aortic stenosis

Accumulation of amyloid in the myocardium

A 50-year-old female presents with a holosystolic murmur heard best over the apex, radiating to the axilla. She has no signs of pulmonary hypertension or edema. What best explains her lack of symptoms?

The left atrium is compensating with increased compliance

The aorta is compensating with increased compliance

Mitral valve prolapse without regurgitation causes no hemodynamic changes

As long as preload in the left ventricle is maintained there would be no symptoms

The right ventricle is compensating with decreased compliance

A 34-year-old male is brought to the emergency department. He has prior hospitalizations for opiate overdoses, but today presents with fever, chills, rigors and malaise. On physical exam vitals are temperature: 100.5 deg F (38.1 deg C), pulse is 105/min, blood pressure is 135/60 mmHg, and respirations are 22/min. You note the following findings on the patient's hands (Figures A and B). You note that as the patient is seated, his head bobs with each successive heart beat. Which of the following findings is most likely present in this patient?

A water-hammer pulse when palpating the radial artery

A holosystolic murmur at the 4th intercostal midclavicular line

Decreased blood pressure as measured in the lower extremities compared to the upper extremities

A harsh crescendo-decrescendo systolic murmur in the right second intercostal space

A consistent gallop with an S4 component

A 36-year-old man presents to his primary care physician because of shortness of breath. He is an office worker who has a mostly sedentary lifestyle; however, he has noticed that recently he feels tired and short of breath when going on long walks with his wife. He also has had a hacking cough that seems to linger, though he attributes this to an upper respiratory tract infection he had 2 months ago. He has diabetes that is well-controlled on metformin and has smoked 1 pack per day for 20 years. Physical exam reveals a large chested man with wheezing bilaterally and mild swelling in his legs and abdomen. The cause of this patient's abdominal and lower extremity swelling is most likely due to which of the following processes?

Right ventricular dysfunction secondary to pulmonary hypertension

Valvular heart disease and heart failure for USMLE Step 2 CK: High-Yield Internal Medicine Lessons

VHD & HF - Valves Under Pressure

Valvular lesions cause HF via two main pathways based on the type of hemodynamic stress:
- Stenosis: A pressure-loaded ventricle (↑ afterload) undergoes concentric hypertrophy (thickened walls, smaller cavity), leading to impaired relaxation and diastolic HF (HFpEF).
- Regurgitation: A volume-loaded ventricle (↑ preload) undergoes eccentric hypertrophy (dilated cavity), leading to eventual pump failure and systolic HF (HFrEF).

Cardiac hypertrophy types and progression to heart failure

⭐ Acute, severe regurgitation (e.g., post-MI papillary muscle rupture) bypasses chronic remodeling, causing rapid cardiogenic shock.

Aortic Stenosis - The Stubborn Door

Etiology: Age-related (senile) calcification or congenital bicuspid aortic valve.
Pathophysiology: LV outflow obstruction → pressure overload → concentric LV hypertrophy → diastolic, then systolic dysfunction.
Clinical Triad (📌 SAD): Syncope, Angina, Dyspnea are late, ominous signs.
Murmur: Harsh crescendo-decrescendo systolic murmur radiating to carotids. Pulsus parvus et tardus (weak, delayed pulse).
Severity: Valve area <1.0 cm² is severe.

Aortic Stenosis: Pressure Gradient & Pressure-Volume Loop

⭐ The onset of symptoms is a critical prognostic marker. Without valve replacement, average survival is grim: 2 years with syncope, 3 with angina, 5 with dyspnea.

Aortic Regurgitation - The Leaky Gate

Etiology: Aortic root dilation (Marfan syndrome, syphilis), infective endocarditis, rheumatic fever.
Pathophysiology: Backward flow into LV → LV volume overload → eccentric hypertrophy → ↑ stroke volume but eventual systolic dysfunction.
Symptoms & Signs: Palpitations, dyspnea. ↑ Systolic & ↓ diastolic pressure → wide pulse pressure.
- Eponyms: Water-hammer pulse (Corrigan's), de Musset's sign (head bobbing), Quincke's pulses (capillary pulsations).
Murmur: High-pitched, blowing, early diastolic decrescendo murmur best heard at the left sternal border.

Echocardiogram: Aortic Regurgitation Severity

⭐ Exam Favorite: An Austin Flint murmur, a mid-diastolic rumble, can be heard. It's caused by the regurgitant jet striking the anterior mitral valve leaflet, mimicking mitral stenosis.

Mitral Stenosis - The Atrial Jam

Etiology: Almost exclusively rheumatic heart disease.
Pathophysiology: Obstruction at the mitral valve → ↑ LA pressure → LA enlargement → pulmonary hypertension → right-sided HF.
Clinical Features:
- Murmur: Opening snap (OS) followed by a low-pitched mid-diastolic rumble, best heard at the apex.
- Complications: Atrial fibrillation (from LA stretch), hoarseness (Ortner's syndrome), dysphagia.

Echocardiogram: Mitral Stenosis "Hockey Stick" Appearance

⭐ The interval between S2 and the opening snap is inversely proportional to the severity of the stenosis; a shorter S2-OS interval means more severe MS.

Mitral Regurgitation - The Backflow Problem

Etiology: Most commonly from mitral valve prolapse; also ischemic damage to papillary muscles (post-MI), infective endocarditis, or rheumatic heart disease.
Pathophysiology: Backflow into the left atrium (LA) causes volume overload in both the LA and left ventricle (LV).
- Leads to LA enlargement (↑ risk of atrial fibrillation) and eccentric LV hypertrophy.
- Eventually results in systolic dysfunction with a decreased ejection fraction.
Murmur: Holosystolic, blowing murmur best heard at the apex, radiating to the axilla.

Echocardiogram: Mitral Regurgitation with Color Doppler

⭐ The intensity of the MR murmur does not correlate with its severity. A soft murmur can be severe, especially in acute MR where LA pressures are very high.

High‑Yield Points - ⚡ Biggest Takeaways

Aortic stenosis is the most common valvular cause of HF; presents with syncope, angina, and dyspnea (SAD).

Acute regurgitation (aortic/mitral) is a surgical emergency causing pulmonary edema and cardiogenic shock.

Mitral regurgitation has a holosystolic murmur radiating to the axilla.

Mitral stenosis (from rheumatic fever) leads to atrial fibrillation and right-sided HF.

Aortic regurgitation causes a diastolic murmur and wide pulse pressure.

Left-sided valve disease drives pulmonary hypertension and subsequent right-sided HF.

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