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In contrast to the dramatic symptoms associated with acute valvular dysfunction, chronic valvular disease is slowly progressive due to the heart’s ability to dilate or hypertrophy in response to the valvular abnormality. These adaptive responses may preserve cardiac function and delay the diagnosis of chronic valvular disease for decades. Emergency physicians usually encounter patients with valvular disease after the diagnosis has been made but occasionally are the first to suspect valvular dysfunction based on the patient’s symptoms and examination. Compared with the general population, patients with hemodynamically significant valvular heart disease have a 2.5-fold higher death rate and a 3.2-fold increased rate of stroke.1

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Normal heart valves allow efficient blood flow through the cardiac chambers and prevent retrograde flow. Valvular dysfunction can manifest as incompetence or stenosis and can be caused by abnormalities of the valvular cusps, papillary muscles, chordae tendineae, or cardiac chambers.

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The first step in diagnosing a newly discovered murmur is to consider it in the context of the patient’s medical condition. Patients with normal cardiac anatomy may have systolic murmurs associated with anemia, arteriovenous fistula, thyrotoxicosis, sepsis, fever, renal failure with volume overload, pregnancy, or other conditions associated with increased cardiac output. A diastolic murmur or a new murmur associated with symptoms at rest should be considered pathologic and warrants an echocardiographic study and referral to cardiology. If there is uncertainty related to the diagnosis of a newly discovered murmur, referral should be made to a cardiologist or the primary care physician. In general, the urgency for an accurate diagnosis and appropriate referral or admission depends on the severity of symptoms, not the presence of the murmur. The exception is the patient with suspected aortic stenosis and syncope who may appear well at rest yet is at risk for a catastrophic cardiovascular event. Benign or physiologic murmurs do not cause symptoms or physical exam findings compatible with cardiovascular disease. Generally, they are soft systolic ejection murmurs that begin after S1, end before S2,and are not associated with other abnormal heart sounds. Figure 58-1 presents an algorithm for the assessment of a newly discovered murmur.2 Table 58-1 lists a grading system for murmurs to aid the use of Figure 58-1.

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Figure 58-1.
Graphic Jump Location

Algorithm for evaluation of newly discovered systolic murmur. CXR = chest x-ray.

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Table Graphic Jump Location
Table 58-1 A Grading System for Murmurs
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New cardiac murmurs, especially those of valvular insufficiency, can also be a sign ...

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