EpistemisApical holosystolic murmur (Bar murmur)
Specialty: Cardiovascular.
Why it occurs
- Chronic mitral valve regurgitation (degenerative, myxomatous, rheumatic or functional)
- Acute mitral regurgitation secondary to rupture of chordae tendineae or papillary muscle dysfunction (due to myocardial infarction)
- Severe tricuspid regurgitation (organic or functional due to pulmonary hypertension)
- Restrictive or obstructive ventricular septal defect (VSD)
Initial workup
Emergency transthoracic and transesophageal echocardiogram (TEE) to define the etiology and mechanism of valvular insufficiency (e.g., prolapse, flail, restriction, calcification or chordal rupture), quantify the area of the effective regurgitant orifice (EROA >=0.4 cm2 indicates severity in organic mitral insufficiency) and the regurgitant volume, evaluate left ventricular systolic function (LVEF) and estimate pulmonary artery systolic pressure; Electrocardiogram to identify arrhythmias (atrial fibrillation) or myocardial ischemia; Chest x-ray.
red flags
Rough or blowing holosystolic murmur that occupies the entire systole from R1 to R2, audible at the apex and radiating classically to the left axilla (mitral insufficiency) or audible at the low left sternal border that increases in intensity with inspiration (Rivero-Carvallo sign, tricuspid insufficiency), of sudden onset in the context of an acute myocardial infarction or chest trauma, associated with extreme dyspnea at rest, orthopnea, generalized bilateral pulmonary crackles, profound hypotension, skin coldness or cardiogenic shock. It suggests acute catastrophic valve insufficiency or interventricular septal rupture, representing a vital surgical emergency.
Standard management
- Sodium nitroprusside — ultra-rapid-acting arterial vasodilator indicated in severe acute mitral insufficiency or VSD to reduce left ventricular afterload, favor antegrade ejection volume and reduce regurgitant flow; continuous infusion of 0.3 to 3 mcg/kg/min under invasive blood pressure monitoring
- Intravenous nitroglycerin — venous vasodilator and inotropic to reduce pulmonary congestion; infusion 10 to 100 mcg/min
- Furosemide — loop diuretic indicated for the management of pulmonary venocapillary congestion; 40 to 80 mg intravenous bolus
- Enalapril (ACEI indicated for maintenance in compensated chronic mitral insufficiency for the long-term management of ventricular afterload and remodeling; 5 to 10 mg twice daily orally).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Cardiovascular
- Listed causes
- 4
- Treatment options
- 4