Mitral prolapse with Valsalva and squatting? - USMLE Forums
USMLE Forums Logo
USMLE Forums         Your Reliable USMLE Online Community     Members     Posts
Home
USMLE Articles
USMLE News
USMLE Polls
USMLE Books
USMLE Apps
Go Back   USMLE Forums > USMLE Step 1 Forum

USMLE Step 1 Forum USMLE Step 1 Discussion Forum: Let's talk about anything related to USMLE Step 1 exam


Reply
 
Thread Tools Search this Thread Display Modes
  #1  
Old 01-25-2012
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 1,406
Threads: 118
Thanked 644 Times in 408 Posts
Reputation: 654
Stethoscope Mitral prolapse with Valsalva and squatting?

I always understood the mid-systolic click of mitral prolapse to be louder with the valsalva maneuver (as clamping the vena cava means less blood in the heart and therefore you can hear the click louder).

but now i just read pathoma and he said that squatting (which increases TPR, thereby increasing blood in the left heart) increases the mitral prolapse mid-systolic click because of the greater pressure pushing back on the valve.

help?
__________________
"inflammable means flammable!? What a country."
Reply With Quote Quick reply to this message



  #2  
Old 01-25-2012
Hitman's Avatar
USMLE Forums Master
 
Steps History: Not yet
Posts: 928
Threads: 17
Thanked 539 Times in 375 Posts
Reputation: 549
Default

yes valsalva maneuvre increases the murmur as less blood flows through the valve by less preload

according to UW Squatting increases PVR and Preload and cause decrease in intensity of murmur as more blood close the valve leaflets completely , only HCM and MVP murmurs decrease on squatting .........
Reply With Quote Quick reply to this message
  #3  
Old 01-25-2012
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 1,406
Threads: 118
Thanked 644 Times in 408 Posts
Reputation: 654
Default

Quote:
Originally Posted by Hitman View Post
yes valsalva maneuvre increases the murmur as less blood flows through the valve by less preload

according to UW Squatting increases PVR and Preload and cause decrease in intensity of murmur as more blood close the valve leaflets completely , only HCM and MVP murmurs decrease on squatting .........
HCM murmur?

so i just reread pathoma and it says mitral prolapse MURMUR increases, not click... i guess that makes sense, right?
__________________
"inflammable means flammable!? What a country."
Reply With Quote Quick reply to this message
 
  #4  
Old 01-25-2012
Hitman's Avatar
USMLE Forums Master
 
Steps History: Not yet
Posts: 928
Threads: 17
Thanked 539 Times in 375 Posts
Reputation: 549
Default

Quote:
Originally Posted by khushi.chahal View Post
HCM murmur?

so i just reread pathoma and it says mitral prolapse MURMUR increases, not click... i guess that makes sense, right?

No , according to UW squatting decrease MVP murmur not increase which pathoma says .......

HCM produces a systolic ejection murmur which also decrease on squatting ...
Reply With Quote Quick reply to this message
The above post was thanked by:
Dr.NickRiviera (01-25-2012)
  #5  
Old 01-25-2012
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 1,406
Threads: 118
Thanked 644 Times in 408 Posts
Reputation: 654
Default

Quote:
Originally Posted by Hitman View Post
No , according to UW squatting decrease MVP murmur not increase which pathoma says .......

HCM produces a systolic ejection murmur which also decrease on squatting ...
whats HCM?
__________________
"inflammable means flammable!? What a country."
Reply With Quote Quick reply to this message
  #6  
Old 01-25-2012
Hitman's Avatar
USMLE Forums Master
 
Steps History: Not yet
Posts: 928
Threads: 17
Thanked 539 Times in 375 Posts
Reputation: 549
Default

Quote:
Originally Posted by khushi.chahal View Post
whats HCM?

Hypertrophic cardiomyopathy
Reply With Quote Quick reply to this message
  #7  
Old 01-25-2012
USMLE Forums Scout
 
Steps History: ---
Posts: 58
Threads: 1
Thanked 140 Times in 19 Posts
Reputation: 150
Default

Check this out

Mitral prolapse with Valsalva and squatting?-mvp-squatting-standing.jpg
click image to enlarge

The click to S1 interval is less with Valsalva but the murmur is longer
Reply With Quote Quick reply to this message
The above post was thanked by:
amit chahar (07-04-2012), Dr.NickRiviera (01-25-2012), Moloch (01-26-2012), YoramFishke (05-04-2012)
  #8  
Old 01-25-2012
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 1,406
Threads: 118
Thanked 644 Times in 408 Posts
Reputation: 654
Default

what about aortic stenosis? with increased TPR, that murmur should decrease too right?
__________________
"inflammable means flammable!? What a country."
Reply With Quote Quick reply to this message
  #9  
Old 01-26-2012
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 646
Threads: 52
Thanked 761 Times in 256 Posts
Reputation: 772
Default

Quote:
Originally Posted by khushi.chahal View Post
what about aortic stenosis? with increased TPR, that murmur should decrease too right?
nope that increases.. cos of more blood returning to the heart.. hence more getting pumped out..


HCM and MVP are the only two exceptions to the rule
Reply With Quote Quick reply to this message
The above post was thanked by:
Dr.NickRiviera (01-26-2012)
  #10  
Old 05-04-2012
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 1,406
Threads: 118
Thanked 644 Times in 408 Posts
Reputation: 654
Default Mitral Valve Prolapse: murmur decreases or increases with squatting?

Just did a question where someone has MVP and in the stem they say squatting makes the murmur disappear.
Because of this I changed my diagnosis to ASD but it turns out it was MVP after all, and in the explanation they saying squatting relieves the murmur (they claim it increases preload and 'augments' afterload).

I was under the understanding that squatting would make the murmur worse? And FA 2011 pg. 259 agrees with me.

Which is it?
__________________
"inflammable means flammable!? What a country."
Reply With Quote Quick reply to this message
  #11  
Old 05-04-2012
K06100's Avatar
USMLE Forums Master
 
Steps History: 1+CK+CS+3
Posts: 730
Threads: 90
Thanked 456 Times in 289 Posts
Reputation: 466
Default UW says opposite

Quote:
Originally Posted by Dr.NickRiviera View Post
Just did a question where someone has MVP and in the stem they say squatting makes the murmur disappear.
Because of this I changed my diagnosis to ASD but it turns out it was MVP after all, and in the explanation they saying squatting relieves the murmur (they claim it increases preload and 'augments' afterload).

I was under the understanding that squatting would make the murmur worse? And FA 2011 pg. 259 agrees with me.

Which is it?

but UW says murmur decreases on squatting.......with squatting all murmurs become louder except HCM and MVP......!!!!
__________________
Try Not To Become A Man Of Success But A Man Of Value.
Reply With Quote Quick reply to this message
  #12  
Old 05-04-2012
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 1,406
Threads: 118
Thanked 644 Times in 408 Posts
Reputation: 654
Default

Quote:
Originally Posted by K06100 View Post
but UW says murmur decreases on squatting.......with squatting all murmurs become louder except HCM and MVP......!!!!
squatting = increased PVR = increased afterload = more blood in the LV pushing back on the messed up mitral valve = more prolapse and regurg.

i dont see how the murmur in MVP could be less on squating :/
__________________
"inflammable means flammable!? What a country."
Reply With Quote Quick reply to this message
  #13  
Old 05-04-2012
Hope2Pass's Avatar
USMLE Forums Master
 
Steps History: 1+CK+CS+3
Posts: 1,684
Threads: 213
Thanked 1,595 Times in 660 Posts
Reputation: 1605
Default

Quote:
Originally Posted by Dr.NickRiviera View Post
squatting = increased PVR = increased afterload = more blood in the LV pushing back on the messed up mitral valve = more prolapse and regurg.

i dont see how the murmur in MVP could be less on squating :/
I thought with squatting you increase the preload by increasing the venous return ? Doesn't the preload increase which increases the LVEDV ?
Reply With Quote Quick reply to this message
  #14  
Old 05-04-2012
USMLE Forums Master
 
Steps History: 1 + CS
Posts: 675
Threads: 84
Thanked 427 Times in 206 Posts
Reputation: 437
Default

i got mixed up with that too, it took me an hour of looking up stuff to realize that maybe FA is wrong!

I downloaded the official FA errata thingy, it says the following:

Correction for p.259:
In the entry for mitral prolapse, change the last sentence to read, “Enhanced by maneuvers that ↓venous return (e.g., standing or Valsalva).”

Reply With Quote Quick reply to this message
The above post was thanked by:
Dr.NickRiviera (05-04-2012)
  #15  
Old 05-04-2012
USMLE Forums Master
 
Steps History: 1 + CS
Posts: 675
Threads: 84
Thanked 427 Times in 206 Posts
Reputation: 437
Default

Regarding MVP, the UW annotation i wrote down next to it is:

(valsalva maneuver and standing position) are used to differentiate between systolic murmurs in the left heart.
Both of these maneuvers decrease VR to the heart, thereby decreasing LV volume (and pressure).

So, with decreased VR:
More audible----> MVP, HTC
Less audible----> Aortic stenosis
Reply With Quote Quick reply to this message
The above post was thanked by:
amit chahar (07-04-2012), Hope2Pass (05-04-2012)



  #16  
Old 05-04-2012
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 1,406
Threads: 118
Thanked 644 Times in 408 Posts
Reputation: 654
Default

Quote:
Originally Posted by Renaissance View Post
i got mixed up with that too, it took me an hour of looking up stuff to realize that maybe FA is wrong!

I downloaded the official FA errata thingy, it says the following:

Correction for p.259:
In the entry for mitral prolapse, change the last sentence to read, “Enhanced by maneuvers that ↓venous return (e.g., standing or Valsalva).”


alright if its in the errata then fcuk it, ima just memorize it as thats what itll be on the step.

solved once and for all!
__________________
"inflammable means flammable!? What a country."
Reply With Quote Quick reply to this message
  #17  
Old 05-04-2012
YoramFishke's Avatar
USMLE Forums Veteran
 
Steps History: 1+CK+CS
Posts: 248
Threads: 11
Thanked 308 Times in 127 Posts
Reputation: 338
Default

I think post number 7 is the most accurate thing that we should go by
Reply With Quote Quick reply to this message
  #18  
Old 04-09-2014
USMLE Forums Master
 
Steps History: 1+CK+CS+3
Posts: 592
Threads: 92
Thanked 196 Times in 128 Posts
Reputation: 206
Send a message via Skype™ to drpisho
Default

FA 2014 says Valsalva phase II:

decreases intensity of MOST murmurs (including MVP)
except in HCM where it increases.

is this accurate then? i thought so too that valsalva phase II would INCREASE MVP murmur.
please confirm!

drives me crazy cause i just did an uworld question where the explanation states THAT ALL MURMURS ARE DECREASED ON valsalva phase II except MVP and HCM.

anyone encountered the same problem?
i just took a peek at FA 2014 errata and nothing there about this.
please someone help? should i go for uworld explanation or uworld is wrong and FA is right??
__________________
Will. Power. Faith. MATCHED IM 2016!

Last edited by drpisho; 04-09-2014 at 01:42 PM.
Reply With Quote Quick reply to this message
  #19  
Old 04-11-2014
USMLE Forums Master
 
Steps History: 1+CK+CS+3
Posts: 592
Threads: 92
Thanked 196 Times in 128 Posts
Reputation: 206
Send a message via Skype™ to drpisho
Thumbs Up

Pleaaaase anyone help me, i cant believe anyone hasnt encountered with this in 2014.
should i go with FA 2014 or UWORLD??

im going crazy about this and i guess ill be going with UWORLD since its updated continuously.

VALSALVA Phase II decreases ALL murmurs (due to decreased VR)
EXCEPT MVP and HCM which will be INCREASED.

there im staying with this!!! lol
__________________
Will. Power. Faith. MATCHED IM 2016!
Reply With Quote Quick reply to this message
  #20  
Old 08-03-2014
USMLE Forums Addict
 
Steps History: 1+CK+CS
Posts: 198
Threads: 26
Thanked 175 Times in 79 Posts
Reputation: 185
Default MVP with squatting & valsalva

MVP is enhanced by Valsalva maneuvers and decreased by squatting.
This is because those maneuvers which decrease the volume of the left ventricle (Valsalva, standing) will cause the prolapse to occur sooner and more severely, while those that increase venous return and diastolic filling (squatting) and thereby enhance the ventricular volume, help to maintain tension along the chordae and to keep the valve shut. The only other murmur which, for similar reasons, responds in this paradoxical way to these common maneuvers is hypertrophic cardiomyopathy, also known as idiopathic hypertrophic subaortic stenosis.

ref. http://www.med.ucla.edu/wilkes/MVPmain.htm
__________________
Step 1 [240]; Step 2 CS [passed first time]; Step 2 CK [244]; YOG (2006); residency in my own country (2013);13 months USCE/Research; GC holder
Reply With Quote Quick reply to this message
The above post was thanked by:
darbi (03-28-2016), Desmin (02-05-2017), drpisho (08-05-2014), excellence (08-12-2014), Mr.wonderful (03-19-2015), Romaniv (07-14-2016)
  #21  
Old 08-05-2014
USMLE Forums Master
 
Steps History: 1+CK+CS+3
Posts: 592
Threads: 92
Thanked 196 Times in 128 Posts
Reputation: 206
Send a message via Skype™ to drpisho
Wink

thanks for the response!! even though i already did step1 i went for your choice too, which is sustained by FA2013 and uworld but overruled by FA 2014
__________________
Will. Power. Faith. MATCHED IM 2016!
Reply With Quote Quick reply to this message
  #22  
Old 09-30-2014
USMLE Forums Newbie
 
Steps History: Not yet
Posts: 4
Threads: 1
Thanked 0 Times in 0 Posts
Reputation: 10
Default

It's driving me crazy too... M doing usmlerx and solving with fa13.. And comparing with fa14 it's opposite!!!
Fa13 : MVP murmur increases with valsalva and decreases with squatting
Fa14 : MVP murmur decreases with valsalva and increases with squatting?

Help!help!
Reply With Quote Quick reply to this message
  #23  
Old 09-30-2014
USMLE Forums Scout
 
Steps History: Not yet
Posts: 44
Threads: 14
Thanked 9 Times in 9 Posts
Reputation: 19
Default

check errarta http://www.firstaidteam.com/proposed...-errata-view-2
they say they made a mistake so it goes like this:

Valsalva-increased murmur intensity, earlier onset of click/murmur
Rapid squatting-decreased murmur intensity, later onset of click/murmur
HOWEVER hand grip maneuver is unknown pathohysiology with somehow causing increased murmur intensity with later onset click/murmur
Reply With Quote Quick reply to this message
The above post was thanked by:
Desmin (02-05-2017)



Reply

Tags
Cardiovascular-, Clinical-Signs, Physiology-, Tables-

Quick Reply
Message:
Options

Register Now

In order to be able to post messages on the USMLE Forums forums, you must first register.
Please enter your desired user name, your email address and other required details in the form below.
User Name:
Password
Please enter a password for your user account. Note that passwords are case-sensitive.
Password:
Confirm Password:
Email Address
Please enter a valid email address for yourself.
Email Address:
Medical School
Choose "---" if you don't want to tell. AMG for US & Canadian medical schools. IMG for all other medical schools.
USMLE Steps History
What steps finished! Example: 1+CK+CS+3 = Passed Step 1, Step 2 CK, Step 2 CS, and Step 3.

Choose "---" if you don't want to tell.

Favorite USMLE Books
What USMLE books you really think are useful. Leave blank if you don't want to tell.
Location
Where you live. Leave blank if you don't want to tell.

Log-in

Human Verification

In order to verify that you are a human and not a spam bot, please enter the answer into the following box below based on the instructions contained in the graphic.



Thread Tools Search this Thread
Search this Thread:

Advanced Search
Display Modes


Similar Threads
Thread Thread Starter Forum Replies Last Post
Mitral Prolapse Murmur and Squatting! belindalimm USMLE Step 1 Forum 7 02-28-2013 08:34 AM
Valsalva Maneuver and Murmur of Mitral Regurgitation emad kadri USMLE Step 2 CK Forum 6 09-20-2011 02:22 AM
mitral valve prolapse chienpolska USMLE Step 1 Forum 1 09-11-2011 09:25 PM
Mitral valve prolapse question aksyonez USMLE Step 2 CK Forum 4 07-01-2011 01:16 PM
Mitral Valve Prolapse and Panic Attacks! Jeanne87 USMLE Step 2 CK Forum 1 06-09-2010 11:53 AM

RSS Feed
Find Us on Facebook
vBulletin Security provided by vBSecurity v2.2.2 (Pro) - vBulletin Mods & Addons Copyright © 2017 DragonByte Technologies Ltd.

USMLE® & other trade marks belong to their respective owners, read full disclaimer
USMLE Forums created under Creative Commons 3.0 License. (2009-2014)