The Daily PANCE and PANRE Extended Edition: Question 19

During a sports ‘screening physical’ examination, a 15-year-old male is noted to have a murmur. You perform bedside maneuvers in an attempt to delineate which type of murmur you are auscultating. Which of the following would be the finding associated with the highest risk of sudden death for this patient?

1. the intensity of the murmur increases during a Valsalva maneuver
2. the intensity of the murmur decreases during standing
3. the murmur does not change while the patient squat
4. the intensity of the murmur decreases during exercise
5. elevation of the legs while the patient is supine increases the intensity of the murmur

Answer: A

The intensity of the murmur increases during a Valsalva maneuver

Hypertrophic cardiomyopathy (most common cause of sudden cardiac death in this age individual) would have a systolic ejection murmur which would INCREASE with Valsalva (decreased preload causing a smaller LV volume and an increase in the obstruction) The murmur would DECREASE with squat or elevating the legs (increase preload, make the LV volume larger and decrease the obstruction)