Course 03: Cardiovascular, Vascular and Hematology
Lesson 6 of 12. Read the diagnostic framework and case, then complete the 10-question practice set. All material is original educational content; high-risk presentations require emergency referral.
Murmur and valve assessment
- Use symptom history and focused auscultation to assess murmurs: onset, timing, radiation, positional changes, dyspnea, exertional syncope and HF signs.
- Symptomatic aortic stenosis may present with exertional angina, dyspnea and syncope; assess urgently and obtain echocardiography.
- Mitral regurgitation can cause an apical pansystolic murmur and pulmonary congestion; echo defines severity and ventricular effects.
- Acute severe valve regurgitation may cause flash pulmonary edema and shock even without a loud chronic murmur.
Endocarditis
- Fever with new murmur, embolic signs, positive blood cultures or a prosthetic valve raises concern for infective endocarditis.
- When stable, obtain appropriate blood cultures before antibiotics as directed by the treating emergency/inpatient team; do not delay antibiotics in sepsis.
- Echocardiography and specialist-directed microbiology assess vegetations and complications.
- Prompt referral is needed for suspected endocarditis, especially with HF, neurological deficit or sepsis.
Rheumatic heart disease
- Prior rheumatic fever can lead to chronic mitral stenosis/regurgitation and AF; a low-pitched diastolic rumble suggests mitral stenosis.
- Acute rheumatic fever follows group A streptococcal infection and is diagnosed using clinical criteria with evidence of preceding infection.
- Rheumatic mitral stenosis has important implications for anticoagulation selection when AF is present.
- Appropriate prevention and long-term specialist follow-up reduce recurrent rheumatic injury.
Congenital and inherited disease
- A bicuspid aortic valve is associated with premature valve stenosis and possible aortopathy requiring imaging follow-up.
- Adult congenital heart disease may present with cyanosis, murmurs, arrhythmia or exercise limitation; refer complex lesions to specialty services.
- Family history of inherited cardiomyopathy, unexplained sudden death or thoracic aneurysm can warrant cardiogenetic evaluation.
- Pregnancy modifies hemodynamics and the risk profile of severe valve disease or aortopathy.
When to escalate
- Urgent red flags: new murmur plus fever/sepsis, syncope with severe stenosis, sudden pulmonary edema or embolic neurological deficits.
- Do not use exercise stress testing for symptomatic severe aortic stenosis without specialist oversight.
- Explain echocardiographic findings in patient-centred terms and coordinate with cardiology for surveillance/intervention decisions.
Applied clinical case
A 70-year-old with exertional syncope has a harsh systolic ejection murmur at the right upper sternal edge radiating to the carotids.
Show model clinical reasoning and disposition
Suspect symptomatic aortic stenosis; arrange urgent echocardiography and cardiology evaluation, and avoid treating this as uncomplicated vasovagal syncope.
Clinical self-check
- Which findings support aortic stenosis?
- Which symptoms indicate high risk?
- How does rheumatic mitral stenosis change AF care?
Guidelines and further learning
- Canadian Cardiovascular Society — Guidelines Library (external)
- AHA/ACC — Atrial Fibrillation Clinical Practice Guideline (external)