Rough systolic ejection murmur (Jet murmur)

Specialty: Cardiovascular.

• ejection systolic murmur of aortic or pulmonary stenosis
• rude crescendo-decrescendo breath

Why it occurs

• Senile or rheumatic calcific aortic valve stenosis
• Congenital aortic stenosis (univalve or bicuspid)
• Congenital pulmonary valve stenosis
• Obstructive hypertrophic cardiomyopathy
• Aortic valve sclerosis (lower intensity murmur without significant gradient)

Initial workup

Two-dimensional transthoracic echocardiogram and continuous Doppler to quantify the area of ​​the aortic or pulmonary valve using the continuity equation, measure the mean pressure gradient (severity if >40 mmHg) and the maximum gradient, evaluate the degree of left ventricular hypertrophy and quantify the ejection fraction; Electrocardiogram to assess left ventricular overload and hypertrophy; Chest x-ray to rule out venocapillary congestion and calcification of the aortic valve.

Standard management

• Furosemide — loop diuretic indicated with extreme caution and at low doses if signs of pulmonary congestion coexist, ensuring that the decrease in preload does not induce severe hypotension due to fixed output; 10 to 20 mg orally per day
• Nitroglycerin — indicated for anginal pain under strict hospital hemodynamic monitoring; slow intravenous infusion or sublingual spray, avoiding profound hypotension
• Atorvastatin — statin indicated to reduce general cardiovascular risk in the presence of associated atherosclerosis; 40 mg once daily orally
• Ramipril (ACEI that can be used with extreme caution and at minimum doses for the strict control of concomitant systemic hypertension in patients with aortic stenosis; starting with 1.25 mg per day orally).