Murmur Evaluation

A 27-year-old woman presents as a new patient to your practice.  She is without chief complaint. She asks to, “get a refill on my birth control pills” , having used combined oral contraceptives for the past 12 years without adverse effects.  Social history reveals she is a nonsmoker, without recreational drug use, drinks approximately 1-2 mixed drinks per week, and runs 2-3 miles 5 days a week with reported excellent activity tolerance. Her health history is generally unremarkable, but with patient report of a “mild heart murmur that was picked up when I was a teenager during a physical I needed so I could run track. I was told not to worry about it.” Physical exam is unremarkable with the exception of a mid-systolic click followed by a grade II mid to late systolic murmur without radiation. The remainder of the cardiac exam is within normal limits. 

These findings most likely represent which type of murmur?

A. Physiologic

B. Aortic stenosis

C. Mitral regurgitation

D. Mitral valve prolapse
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Transcript

Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question, so you can better understand how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: A 27-year-old woman presents as a new patient to your practice. She is without chief complaint and asks to “get a refill on my birth control pills.” Having used combined oral contraceptives for the past 12 years without adverse effects. Social history reveals she is a nonsmoker without recreational drug use. Drinks approximately 1 to 2 mixed drinks per week and runs 2 to 3 miles 5 days a week, with reported excellent exercise tolerance. 

Her health history is unremarkable, with the exception of a patient report of a mild heart murmur that was picked up “when I was a teenager during a physical I needed so I could run track. I was told not to worry about it.” Physical exam is unremarkable, with the exception of a mid-systolic click followed by a grade II mid to late systolic murmur without radiation. 

The rest of the cardiac exam is within normal limits. These findings most likely represent which type of murmur? 

A: Physiologic. 

B: Aortic stenosis. 

C: Mitral regurgitation. 

D: Mitral valve prolapse.  

The correct answer is D: Mitral valve prolapse. Where should you start? First, determine what kind of question this is. This is one of those test items that will likely be classified as an assessment question, where we're given history and physical exams. 

Objective and subjective information. Then ask what these findings could represent. A bit of background information: the scenario here presents an adult with a heart murmur that's likely been present for more than 10 years. In other words, she's telling you, I've had this murmur for a while and I've been told, don't worry about it. And she remains quite physically active. 

To recall, a heart murmur is sound produced by turbulent blood flow across a heart valve or blood vessel, and the turbulence is sufficient to result in a sound loud enough to hear with a stethoscope and differs from normal heart sounds. Heart murmurs have distinct pitch timing, quite specific to the cardiac etiology. With virtually all clinical conditions-and I've mentioned this many times in these podcasts-there are contributing factors to the development of each heart murmur equally.  

Each detected heart murmur has a potential for influence on health status, with some being benign and some associated with and causing significant cardiac pathology and potential negative outcomes. With that background information in mind, let's take a look at the question and the answers. And before we do that, I suspect you want more information about our health history. 

You probably want to get her old records from her prior provider. I'm with you. But on the boards, they'll give you enough data to answer the question. And really, not much more. So get rid of the 'yeah, but’ you're thinking of: yeah, but I want to know this. Yeah, but I want to know that. No. Push that to one side. 

Look at the question. Consider every single word is important in the question and the responses. And then dig in to answering the question. 27-year-old woman presents as a new patient to your practice. She is without complaint. She asked to get a refill on my birth control pills. Having used combined oral contraceptives for the past 12 years without adverse effects. 

Social history reveals she is a nonsmoker without recreational drug use. Drinks approximately 1 to 2 mixed drinks per week and runs 2 to 3 miles 5 days a week, with reported excellent exercise tolerance. Her health history is generally unremarkable. The patient does report a mild heart murmur that was “picked up when I was a teenager during a physical so I could run track. I was told not to worry about it.”  

Physical exam is unremarkable, with the exception of a mid-systolic click followed by a grade II mid to late systolic murmur without radiation. The remainder of the cardiac exam is within normal limits. These findings most likely represent what type of murmur? A: Physiologic. This is incorrect. A physiologic heart murmur is noted in the absence of cardiac structural abnormality. 

Some other terms used to describe a physiologic murmur are a functional murmur, benign systolic murmur, and is often what you will hear from patients. I had a heart murmur when I was a kid. It didn't bother me and I outgrew it. So-but the characteristics of a physiologic murmur include an early to mid-systolic murmur that is heard overt but does not radiate beyond the precordium, so it doesn't radiate to the neck and doesn't radiate to the axilla. 

The murmur in this patient is mid to late systolic and is accompanied by a click. Clicks are not heard in physiologic murmurs. Physiologic murmurs are most often heard in children and younger adults, which of course, she fit into that group. Another characteristic of a physiologic murmur is that the patient goes from supine to standing position, and either softens or disappears. 

B: Aortic stenosis. Here is an example of knowing what groups are at highest risk for the development of a condition is important. The most common type of aortic stenosis is calcific in nature and associated with aging. This is a murmur that is systolic, usually found in people over the age of 60, and even more commonly when you're dealing with people in their 70s, 80s, and beyond. 

The murmur is characterized as being systolic, harsh, and radiating to the neck. You'll notice that this woman's murmur is non-radiating. Quite often, the person with aortic stenosis that is clinically evident is also symptomatic, particularly with complaints of dismay or with exertion, because the stenotic aortic valve cannot open widely enough to accommodate the body's need for increased cardiac output. 

None of this adds up in this particular patient. She's not in the right age group. The murmur doesn't sound like it should be aortic stenosis. It's non-radiating. I could just go on that. C:  Mitral regurgitation. One more time: knowing the path of physiology associated with disease is really important. With mitral regurgitation, the leaflet of the mitral valve failed to approximate and closed tightly, allowing blood to regurgitate into the left atrium when it should be in the left ventricle. 

Mitral regurgitation, often seen in hypertensive heart disease and cardiomyopathy. There are other conditions that can lead to it as well. Often, with the development of left ventricular hypertrophy, that alters the mitral valve function. In other words, the murmur of mitral regurgitation is most often seen in older adults with significant cardiovascular disease. This is a murmur that is described as being holosystolic, taking up all of systole with the propensity to radiate to the axilla. One more time: This just doesn't add up in this particular patient.  

D: Mitral valve prolapse. Of course, this is the correct answer. The description of her heart murmur is classic for a mitral valve prolapse. What's happening in mitral valve prolapse is that one of the leaflets of the mitral valve is longer than it should be. So, during the cardiac cycle, when the mitral valves approximate that longer leak leaflet knuckles or buckles up into the left atrium at mid-systole, that's what causes the click that's often but not always heard with MVP.  

And then there is a little leak of blood into the left atrium that results in the murmur. So, buckle mitral valve into the left atrium. There's the click little leak of blood mid systole and beyond. That's the murmur. One way of thinking of the issue with mitral valve prolapse is to imagine for a moment that you wear a size 8 shoe. 

Somehow or another, you manage to squeeze your foot into, let's say, size 6.5 shoe. Okay, so you wear size 8, but you've squished your foot into a 6.5. You get your toes in, you get your heel in. What's the middle of your foot going to do? It's going to buckle because it just can't lie flat the way it's supposed to. 

And that's exactly what's happening with mitral valve prolapse. Mitral valve prolapse is noted in about 2 to 3% of the general population. Some studies say with skilled auscultation, it might even be as high as 5% of the population. People assigned female at birth are twice as likely to have the condition. When compared to males, the majority of people with mitral valve prolapse are unaware that they have it until it's picked up by a healthcare provider. 

And I know I'm reading between the lines here on the information given, but she's currently a runner, and it sounds like she was cleared to run track when she was a teenager because she was told, yeah, you've got a murmur, don't worry about it. And she's continued to run. In other words, there's nothing here to make me think she has difficulty with exercise tolerance.  

And I know in real life I'd gather all the information, but we have enough information here to answer the question. A small percentage of the population with mitral valve prolapse will have tissue redundancy around the mitral valve. More significant mitral regurgitation resulting symptoms. This is often referred to as mitral valve prolapse disease. 

And clearly that's not what is happening in this clinical scenario. And by the way, there is no issue with her taking combined oral contraceptives with the presence of mitral valve prolapse as described here. Key takeaway: common conditions occur commonly. One of the most common reasons to pick up a heart murmur in an otherwise younger adult, as this patient is, will be mitral valve prolapse with more complicated cardiac conditions. 

Other murmur types are often noted. 

Voiceover: Thank you for listening to NP certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast, and for more NP resources, visit FHEA.com.