USMLEGladiator
2009 & still in race
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WHY MVP
1. worsens wid valsalva
2. improves wid squatting
___________________
Chance favors only the prepared mind. - Louis Pasteur.
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| DrAlex_76
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due to elongated chordae tandinae mitral valve leaflet proplapses when it reaches it maximum excursion -----------> therefore anything decrease Left V volume will decrease the murmur and vice versa.
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| ngaybinhyen
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I thought anything increases LV volume would decrease murmur intensity in MVP and HOCM.
Things like handgrip in which afterload is increased would reduce HOCM murmur but increase MVP murmur.
Hope I'm not wrong
-t
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| ngaybinhyen
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The later is not for HOCM and MVP. It is for AS and MR murmurs
Sorry for mistakenly mentioning
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| nightflight1945
banned
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Handgrip will increase TPR and decrease the gradient across the aortic valve in HOCM and it decreases the murmur of HOCM .
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| ngaybinhyen
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I agree, nightflight 
Does it have any impact on MVP?
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| ngaybinhyen
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If I remember correctly,
Handgrip increases preload, so theoretically improves MVP murmur
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| DrAlex_76
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The click and murmur occur earlier with standing, during the strain of the Valsalva maneuver, and with any intervention that decreases LV volumeexaggerating the propensity of mitral leaflet prolapse. Conversely, squatting and isometric exercise, which increase LV volume, diminish MVP, and the click-murmur complex is delayed and may even disappear.
so my bad to the previous post, MVP and HCM are in the same boat of mechanism.
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| DrAlex_76
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ngaybinhyen, handgrip which increases afterload therefore it will be lower blood volume come out of the left ventricle ------> how come it logically increases the preload ?
I think when talking about handgrip, that only increases SVR which means increases preload. Afterload maybe unchanged or increased very little.
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| ngaybinhyen
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DrArlex,
- Isometric exercise (i.e. handgrip) and squatting have similar effects in "dynamic auscultation" of the heart. They both generally increase afterload (SVR or BP) and preload.
- Handgrip does increase arterial pressure (not SVR) due to an increase in CO, so does decrease LVOTO (i.e. HOCM) murmur, decrease/doesn't change AS murmur, and increase MR murmur.
- They both do decrease MVR murmur.
-t.
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| DrAlex_76
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ops , my bad ....i dun know wat wrong to my typing .
The upper part is right " handgrip which increases afterload therefore it will be lower blood volume come out of the left ventricle ------> how come it logically increases the preload ?"
The later , when talkign about handgrip, people only mentions about increase SVR which means increasing AFTERLOAD.
PRELOAD maybe unchanged or increase very little !
Sorry for my " out of mind " previous typing !
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| DrAlex_76
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if u know any paper about handgrip decrease MVP murmur , please elaborate.
Appreciate,
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| ngaybinhyen
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 Hey dude, you're more stubborn than i'm. However, it's ok. I'll show you real stuffs.
...just kidding, hope you dun get offended
Brounward's is my source.
Again, blood flow does not decrease in handgrip (which is isometric exercise). Blood pressure increases makes the LV-AO pressure gradient less. If blood flow decreased, then HOCM murmur would have increased. In handgrip, cardiac output increases, blood pressure increases, but systemic vascular resistance does not.
Please have a look at the attachment
(I was about to say I'm the source. lol)
-t.
Attached Files:
ISOMETRIC EXERCISE post.docx (12 KB, 4 downloads)
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| DrAlex_76
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- They both do decrease MVR murmur.
-t.[/quote]
We all know that in HCM ....basic one.
Now , go back to wat u mentioned above. As far as I know, handgrip does not decrease MVR murmur ?
Secondly, how u think about handgrip in MVP ?
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| ngaybinhyen
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I can't think myself, dude
1. Based on my notes from QBank, handgrip does increase preload (can't remember which Q it belongs to)
2. by Dr Brounward's, it does reduce MVP murmur (the table is from the book and there is reference for it, too)
I did knock on my head when I read that
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| DrAlex_76
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Auscultation
The most important finding is the mid- or late (nonejection) systolic click, which occurs 0.14 s or more after the S1 and is thought to be generated by the sudden tensing of slack, elongated chordae tendineae or by the prolapsing mitral leaflet when it reaches its maximum excursion. Systolic clicks may be multiple and may be followed by a high-pitched, late systolic crescendo-decrescendo murmur, which occasionally is “whooping” or “honking,” and is heard best at the apex. The click and murmur occur earlier with standing, during the strain of the Valsalva maneuver, and with any intervention that decreases LV volume, exaggerating the propensity of mitral leaflet prolapse. Conversely, squatting and isometric exercise, which increase LV volume, diminish MVP, and the click-murmur complex is delayed and may even disappear. Some patients have a midsystolic click without the murmur; others have the murmur without a click. Still others have both sounds at different times.
guess this one is the one u call " Dr Brounward 's " something.
But check this out : http://www.aafp.org/afp/20000601/3343.html
How u think ?
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| DrAlex_76
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and by da way, i dun know why handgrip can increase preload ? could u kind enough to explain ?
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| ngaybinhyen
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thanks for the link
I don't know what's called "submaximal handgrip". I don't know why they say it shift the sounds toward S1.
any maneuver that augments the volume of blood in the ventricle reduces myocardial contractility, or increases LV afterload lengthens the time from onset of systole to initiation of MVP, and the systolic click and murmur move toward S2 (JACC)
I should have emphasized the typical findings of cardiac sounds in MVP. However, the murmur decreases as it moves toward S2.
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| ngaybinhyen
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- most data on exercise have been obtained from right heart cath in the supine position. Higher cardiac outputs are reached during maximal exercise in the erect position, but because of technical limitations of most measuring techniques, submaximal exercise has been preferred, to allow a short steady state for measuring hemodynamic data
--> So they use "submaximal" by convention
- Physical exercise increases HR, venous return, CO, SV, and systolic pressure. Arterial diastolic pressure remains relatively unchanged or decreases slightly and thus pulse pressure increases during exercise
Apparently this type of exercise is not used to assess CV reserve (but dynamic/isotonic exercise=treadmill). And it is a lot easier to perform positioning in dynamic auscultation.
-t.
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| Eagle_303
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ISOMETRIC EXERCISE. This can be carried out simply and reproducibly using a calibrated handgrip device or hand ball. (It is useful to carry out isometric exercise bilaterally simultaneously.) Isometric exercise should be avoided in patients with ventricular arrhythmias and myocardial ischemia, both of which can be intensified by this activity. Handgrip should be sustained for 20 to 30 seconds, but a Valsalva maneuver during the handgrip must be avoided. Isometric exercise results in transient but significant increases in systemic vascular resistance, arterial pressure, heart rate, cardiac output, left ventricular filling pressure, and heart size. As a consequence, (1) S3 and S4 originating from the left side of the heart become accentuated, (2) the systolic murmur of aortic stenosis is diminished as a result of reduction of the pressure gradient across the aortic valve,[158] [159] (3) the diastolic murmur of aortic regurgitation and the systolic murmurs of rheumatic mitral regurgitation and ventricular septal defect increase in intensity, (4) the diastolic murmur of mitral stenosis becomes louder consequent to the increase in cardiac output, and (5) the systolic murmur of hypertrophic obstructive cardiomyopathy diminishes and the systolic click and late systolic murmur of mitral valve prolapse are delayed because of the increased left ventricular volume. Reference : Braunwald: Heart Disease: A Textbook of Cardiovascular Medicine, 6th ed., Copyright © 2001 W. B. Saunders Company
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