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Many patients with chronic cardiac valve abnormalities who present for emergency care have previously established disease. Acute valvular dysfunction can present with significant symptoms, and emergency physicians must be alert to the presenting signs and symptoms to identify the undiagnosed patient. With bedside echocardiography becoming more commonly available, the initial diagnosis of valvular disease may become more common in the ED.


When an emergency provider identifies a new murmur on exam, the first step in the ED is to determine the potential clinical significance of this finding. Benign murmurs are not likely to cause symptoms and may be found incidentally. These are typically soft systolic ejection murmurs and occur after S1 and end before S2 and are not associated with specific symptoms. In contrast, a new diastolic murmur or a new systolic murmur with symptoms at rest warrants emergent echocardiographic imaging and further evaluation. In addition, risks for possible infections such as endocarditis should be considered in patients with a newly discovered murmur and the presence of fever (Fig. 23-1).

Figure 23-1

Algorithm for evaluation of newly discovered systolic murmur. CXR, chest x-ray.


Clinical Features

Mitral stenosis prevents normal diastolic filling of the left ventricle, and dyspnea with exertion is the most common presenting symptom. In the past, hemoptysis was the second most common presenting symptom, but this is less common now that patients are typically diagnosed and treated earlier in the disease course. As the obstructive process progresses, left atrial pressures rise and lead to left atrial enlargement and symptoms of heart failure. Systemic emboli may develop, especially when accompanied by atrial fibrillation, and can result in myocardial, kidney, central nervous system, or peripheral infarction. Most patients with mitral stenosis eventually develop atrial fibrillation due to progressive dilatation of the atria. The classic murmur of mitral stenosis and associated signs are listed in Table 23-1.

Table 23-1

Comparison of Heart Murmurs, Sounds, and Signs

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