Clinical Findings in Heart Failure

A 70 year old man with a 35 year history of hypertension, dyslipidemia, and a 20 year history of type 2 diabetes presents. He was recently diagnosed with systolic heart failure, presenting with dyspnea on exertion and orthopnea. Prior clinical assessment revealed the murmur of mitral regurgitation. Which of the following would the NP anticipate finding on today’s physical exam?  

A. A mid to late systolic murmur that follows a mid systolic click. 

B. In early to mid systolic murmur harsh in quality, that radiates to the neck. 

C. A holosystolic murmur that radiates to the axilla.

D. A localized mid to late diastolic murmur.

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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 70-year-old man with a 35-year history of hypertension, dyslipidemia, and a 20-year history of type 2 diabetes presents. He was recently diagnosed with systolic heart failure with reduced ejection fraction, presenting with dyspnea upon exertion and orthopnea. The prior clinical assessment revealed the murmur of mitral regurgitation. Which of the following would the NP anticipate finding on today's physical exam: 

A: Mid to late systolic murmur that follows a mid-systolic click.  

B: An early to mid systolic murmur harsh in quality that radiates to the neck.  

C: A holosystolic murmur that radiates to the axilla.  

D: A localized mid to late diastolic murmur.  

The correct answer is C: A holosystolic murmur that radiates to the axilla. Where should we start? 

First, determine what kind of a question this is. Given that we're presented with diagnosis of heart failure and we're told what kind of murmur has been heard in the patient, this is an assessment question. In other words, we're being asked, given this diagnosis, what we would expect to find on the physical exam. First, some background information. The murmur of mitral regurgitation arises from the mitral valve incompetency. 

And when a valve is deemed incompetent, it's a valve that doesn't close properly. This incompetency allows a retrograde flow from a high-pressure area. In this case, the left ventricle to an area of lower pressure, the left atrium. When this murmur is heard in the presence of systolic heart failure, or as we have here, one of the contributing major factors is structural changes in the heart. 

This can include left ventricular enlargement that impacts mitral valve function, particularly in the presence of reduced ejection fraction, heart failure, reduced myocardial contractility is also a potential contributor to mitral valve dysfunction. Other mitral regurgitation causes can include endocarditis, rheumatic heart disease, ruptured cordae, or papillary muscle dysfunction, and an MR resulting from rheumatic heart disease, there’s usually also some degree of mitral stenosis, and as an aside, rheumatic heart disease in this country is actually fairly uncommon. 

And that is in part because of our wide availability of antimicrobials that will be used to treat rheumatic fever. That is an antecedent event to the development of rheumatic heart disease. However, we are a global community so that we see patients who have grown up outside the United States. I do in my practice have some patients with rheumatic heart disease because they were unable to get the rheumatic fever treated outside of the United States. 

So, circling back to this patient, please note that he reports symptoms related to reduced cardiac output: orthopnea and dyspnea on exertion. I know when you approach a question or a clinical scenario that has to do with heart murmurs, it does appear to be something that you just need to memorize things and be done with it. 

As you know, I am not a big fan of memorizing. I like more for you to conceptualize and think through and draw on your knowledge base, and sometimes, quite frankly, just use your common sense. But I appreciate it is a challenge to categorize heart murmurs. So, I developed a mnemonic Mr. Pass MVP and Ms. Ard. And I'm going to go over this now. 

You'll also see that this is a mnemonic that a number of other people have taken credit for, but I actually first developed it probably 35 years ago. So, here are the most common systolic heart murmurs. If we go with the Mr. Pass mnemonic. MR stands for mitral regurgitation. P stands for physiologic. In other words, an innocent or a functional murmur. 

A S stands for aortic stenosis. And the last S, on Mr. Pass, his name is systolic. To remind you that these are among the most common systolic murmurs. Now Mr. Pass wins the most valuable player award. So we're going to stick the initials MVP after his name. And that stands for a mitral valve prolapse. Mr. Pass’ best buddy is Miss Ard, and Ms. Ard stands for mitral stenosis, aortic regurg, and Ms. Ard’s last letter in her name is D. To remind you they are diastolic murmurs. With this as background information. Let's go back to the question. A 70-year-old man with a 35-year history of hypertension, dyslipidemia, and a 20-year history of type 2 diabetes presents. He was recently diagnosed with systolic heart failure with reduced ejection fraction, presenting with dyspnea upon exertion and orthopnea. 

Prior clinical assessment revealed the murmur with mitral regurg. Which of the following would the NP anticipate finding on today's physical exam? A: A mid to late systolic murmur that follows a mid-systolic click. This is incorrect and actually describes the murmur of mitral valve prolapse. This condition is found in up to 3% of the population and is usually asymptomatic, with actually a smaller percentage than the 3% having an audible murmur. 

By the way, the murmur associated with mitral valve prolapse is a non-radiating murmur. B: An early to mid systolic murmur with a harsh quality that radiates to the neck. Obviously this is also incorrect. Please keep in mind cardiac anatomy. If a murmur radiates to the neck, that is, it's heard not only over the precordium but also in the carotid, that murmur likely originates from the aortic valve.  

What we have here is the description of aortic stenosis. This murmur is most often heard in older adults; up to 77% of people over the age of 65. And when it's severe, it can lead to reduced cardiac output with heart failure symptoms. So you might say yeah, but this guy has heart failure. 

Yes. But he does not have findings consistent with the murmur of aortic stenosis in older adults. The murmur of the aortic stenosis is most often due to the valve being calcified over time. C: A holosystolic murmur that radiates to the left axilla. This is the correct answer, and describes the classic presentation of the murmur of mitral regurgitation, and holosystolic means that the murmur is the same intensity throughout systole, and the murmur takes up all of systole. 

This is generally a loud-ish murmur, grade 2 to 3, and most of the time it will radiate to the axilla. Now think it through one more time when you're auscultating the chest, auscultating the precordium-where is the mitral region? It is located not at the axilla, but more axilla adjacent. So, it makes sense that that's where the murmur would radiate. 

Keep in mind, on the NP boards, the NP questions will most often include the classic or the typical presentation of the condition. In other words, the rule rather than the exception. Option D, which we obviously know is incorrect. A localized mid to late diastolic murmur. This describes the murmur of mitral stenosis, a condition that is most often associated with rheumatic heart disease. 

If mitral stenosis is due to rheumatic heart disease, there will also invariably be some degree of mitral regurgitation. Part of this is because if the valve is too stiff to open correctly with rheumatic heart disease. It's also too stiff to close correctly. Interestingly 70% of all individuals diagnosed with mitral stenosis are female birth sex assignment. This murmur is usually localized without radiation. 

And the other part-not that I ever want you to approach a question on boards by just saying, gee, most heart murmurs are systolic, so I'm just going to choose the one of the systolic options and not think it through. I'm not telling you that at all, but systolic murmurs will be the vast majority of murmurs that are encountered in clinical practice. 

Diastolic murmurs are far less common. Key takeaway: identifying cardiac murmurs can be daunting. Focusing your study on correlating clinical presentation with the associated murmurs will help guide your studies and enhance your NP ward success. 

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