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Expiration, leg raise, standing
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Expiration, standing, Valsalva
Handgrip, squatting, expiration
Handgrip, squatting, leg raise
Standing, leg raise, Valsalva
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These patients present with a crescendo-decrescendo systolic murmur at the left sternal border and a midsystolic click followed by a uniform, high-pitched murmur at the cardiac apex, indicative of hypertrophic obstructive cardiomyopathy (HOCM) and mitral valve prolapse (MVP), respectively. These murmurs are reduced with maneuvers that increase venous return, such as squatting and passive leg raise, or afterload, such as handgrip. HOCM is caused by ventricular septum hypertrophy and anterior systolic motion of the anterior leaflet of the mitral valve, causing ventricular outflow tract obstruction. These patients can present with sudden collapse and sudden death in young athletes. Its murmur is intensified by maneuvers that decrease venous return (e.g., Valsalva maneuver) or afterload (e.g., abrupt standing). Conversely, its murmur is reduced by maneuvers that increase preload (e.g., leg raise, squatting) or afterload (e.g., handgrip), due to increased left ventricular volume relieving the obstruction. MVP is common in patients with underlying connective tissue disease and its murmur is reduced (delayed) by maneuvers that increase preload and afterload. Thomas et al. describe the physiology of cardiac murmurs and discuss maneuvers that intensify or reduce these murmurs. They discuss how sensitivity and specificity for detecting murmurs can be as high as 70% and 98% in trained individuals. They recommend mastering these murmurs to expedite detection of possible cardiac disease. Incorrect Answers: Answer 1: Expiration, leg raise, and standing is incorrect because both expiration and standing reduce preload, which would increase the murmurs of HOCM and MVP. Decreasing preload can reduce the murmurs of stenotic murmurs such as aortic or pulmonary stenosis. Answer 2: Expiration, standing, and Valsalva is incorrect because all of these maneuvers reduce preload, which would increase the murmurs of HOCM and MVP. Decreasing preload can reduce the murmurs of stenotic murmurs such as aortic or pulmonary stenosis. Answer 3: Handgrip, squatting, and expiration is incorrect because expiration reduces preload. A reduction of preload leads to worsened obstruction in HOCM and intensification of the murmurs of both HOCM and MVP. Decreasing preload can reduce the murmurs of stenotic murmurs such as aortic or pulmonary stenosis. Answer 5: Standing, leg raise, and Valsalva is incorrect because standing and Valsalva reduce preload, which would increase the murmurs of HOCM and MVP. Decreasing preload can reduce the murmurs of stenotic murmurs such as aortic or pulmonary stenosis. Bullet Summary: Maneuvers that increase venous return, such as leg raise or squatting, or afterload, such as handgrip, reduce the murmurs of hypertrophic obstructive cardiomyopathy and mitral valve prolapse.
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