Maryjoe
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Hi guys, I need some help! I'm having headaches trying to remember what maneuvers (valsalva, leg rise, hand grip, squat etc etc) increse or decrese the murmurs in Valvular anomalies/diseases, any tips??, pleaaseee I'll apreciate it very much!!!!
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| DrVirgo
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Phenylephrine (alpha-1 agonist) and Handgrip both have the same effect ---They cause arteriolar vasoconstriction. This causes an increase in afterload, which means an increase in pressure in the aorta and therefore a decrease flow across the aortic valve.
For Mitral Regurg, this will INCREASE the murmur because the increase pressure in the aorta will allow MORE blood to regurg across the mitral valve.
For VSD, its the same principle... More pressure will cause MORE blood to flow across the VSD and increase the murmur.
For Aortic stenosis, the increased pressure in the aorta and decrease flow across the aortic valve will DECREASE the murmur.
And the same for HOCM... The less pressure and flow across the aortic valve, means the murmur will be decreased.
Now lets look at the opposite situation: Amyl Nitrate which causes arteriolar VASODILATION.. This causes Decreased pressure in the Aorta and INCREASED flow across the aortic valve.
For MR, this means less blood can regurg back from the LV to the LA, so the murmur will be reduced.
For VSD, again same thing -less pressure, less blood across the septal defect so the murmur will be reduced.
For Aortic Stenosis, MORE flow across the Aortic valve will obviously intensify the murmur.
Same for HOCM... the decreased pressure and increased flow will allow more blood to pass through the aortic valve and intensify the murmur.
I hope I've explained it ok...
If anyone has another or better /easier way to explain it, please do! 
Thanks.
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| DrVirgo
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Squatting, and Leg Raise will INCREASE PRELOAD.
More blood in the heart will exacerbate or increase the murmurs of MS, AS, MR, and AR.
And will relieve or decrease the murmurs of HOCM, and MVP.
Treat with things that DECREASE Preload like ACE-I, Diuretics, (dig if indicated).
Valsalva or Standing will DECREASE PRELOAD.
Less blood in the heart will relieve or decrease the murmurs of MS, AS, MR, and AR.
And will exacerbate or increase the murmurs of HOCM and MVP.
Treat with things that INCREASE Preload like Beta-Blockers.
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| arlete
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Valsalva manouver: the increase in the chest pressure forces the blood out of the heart, so it decreases the left ventricular volume, which increases the murmur of mitral valve prolapse and HOCM. The gradient between LV and aorta decreases, so it decreases the aortic stenosis murmur. Same for pulmonic stenosis and tricuspide regurgitation. Think "less blood inside the heart".
Anything that increases the LV volume will decrease the MVP and HOCM murmurs, because it will expand the LV, so the anatomic aspect will be "less abnormal". For example, the leg rise, squatting and inspiration (increase preload). These increase the gradient in aortic stenosis, increasing the murmur. It increases PS and TR too.
The others were well explained by Dr. Virgo.
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| Maryjoe
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Hey tanks for your anwers!!
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| arlete
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