First Aid Errata Questions-Mitral Valve Prolapse+

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JP2740

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Ok they pulled a switcharoo on the latest first aid errata for 2013.

Valsalva = decreased MVP murmur intensity and click happens closer to S1
Squatting = increased MVP murmur intensity and click happens closer to S2

This is in contrast to a lot of sources I've read before - Goljian, wiki, lecture notes. Goljian said the complete opposite, valsalva = decreased venous return = increased MVP murmur AND click closer to S1, squatting = increased venous return = decreased murmur AND click closer to S2. First aid doesn't even agree that if you increase the murmur, the click is closer to S1 (according to goljian).

1) What the hell to think here?

Another first aid thing for antithrombin 3 deficiency. It says PTT is normalized after heparin administration. Do they mean the PTT stays the same after heparin is added? I thought maybe decreased antithrombin 3-> increased coagulation/consumption of factors -> increased PTT, and thus if u add enough heparin to ramp up the existing antithrombin 3 you can throw off that process.

2) So my question is, in antithrombin 3 deficiency, is there normally an increased PTT that is then brought down by heparin, or do they mean heparin no longer increases the PTT?

I'll take this to complicated concept thread if no one answers.
 
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2) In a normal patient, heparin increases PTT of course. But if the patient has AT3 deficient, normal dosages of heparin will not change PTT. Give them a high enough dose and it will, since AT3 is not completely absent
 
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Pinkleton said:
2) In a normal patient, heparin increases PTT of course. But if the patient has AT3 deficient, normal dosages of heparin will not change PTT. Give them a high enough dose and it will, since AT3 is not completely absent
Click to expand...

Ok just thought the wording was weird with the new errata
 
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JP2740 said:
Ok they pulled a switcharoo on the latest first aid errata for 2013.

Valsalva = decreased MVP murmur intensity and click happens closer to S1
Squatting = increased MVP murmur intensity and click happens closer to S2

This is in contrast to a lot of sources I've read before - Goljian, wiki, lecture notes. Goljian said the complete opposite, valsalva = decreased venous return = increased MVP murmur AND click closer to S1, squatting = increased venous return = decreased murmur AND click closer to S2. First aid doesn't even agree that if you increase the murmur, the click is closer to S1 (according to goljian).

1) What the hell to think here?
Click to expand...

Let me give this one a shot.

MVP happens due to the lengthening of the chordae tendinae that hold the valve in the correct place during diastole. So any maneuver that increases volume of the heart will decrease the murmur, as the valve is closer to its normal position.

The "click" you can think of as the chordae tendinae snapping, like if you have a loose string and you suddenly tighten it.

Valsalva will reduce venous return to the heart, so there will be less volume and thus more mismatch between the length of the chordae tendinae and the distance to the left atrium, so a louder and earlier snap, closer to S1.

Squatting will effectively increase arteriole resistance, increasing the pressure that the heart will push against. So the end diastolic volume will be higher and decrease the mismatch. You'll end up with a later murmur and a shorter one, so closer to S2.

So, you're not crazy - it just sounds like they just switched 'decreased' and 'increased'.
 
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Wait you are saying your first aid says that squatting incresaes the intensity of MVP?

Mine says it decresaes the intensity, which is right. Squatting would initially increases venous return, contributing to a decrease in intensity. With prolonged squatting, you would additionally get an increase in afterload, which would additionally decrease the intensity.

Any my first aid doesn't even mention whether a worse murmur has a click closer to S1 or S2. It just says that it is loudest at S2, which makes sense since it is a crescendo murmur.

Basically, my FA somehow seems to correlate with what Goljan says.

The one thing that might be confusing is valsalva RELEASE. this phase you have an increase in blood flow back to the heart so an effective decrease in the intensity of MVP. As opposed to phase 2 of the valsalva, where you have an increased in intrathoracic pressure, decreasing venous return and thus increasing the intensity of MVP.
 
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Thanks to the first aid errata page, my annotations for murmur maneuevers is a mess. I don't even look at it anymore.
 
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From what I remember from class valsalva increases MVP and hypertrophic cardiomyopathy...but every other murmur decreases in squatting position.

I've still yet to get to the whole "Why?" scenarios.
 
Last edited:
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Pinkleton said:
2) In a normal patient, heparin increases PTT of course. But if the patient has AT3 deficient, normal dosages of heparin will not change PTT. Give them a high enough dose and it will, since AT3 is not completely absent
Click to expand...

JP2740 said:
Ok just thought the wording was weird with the new errata
Click to expand...

My interpretation is, in a patient with AT3 defeciency their PTT is going to normally be DECREASED, due to an increase to the tendency to clot. If you give them Heparin, they will then have a normal PTT
 
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skyblue2000 said:
From what I remember from class valsalva increases MVP and hypertrophic cardiomyopathy...but every other murmur decreases in squatting position.

I've still yet to get to the whole "Why?" scenarios.
Click to expand...

There's a really solid explanation in the "difficult concepts thread". Someone did a good job of explaining the diff between prolapse and regurg in there.
 
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sharklasers said:
Wait you are saying your first aid says that squatting incresaes the intensity of MVP?

Mine says it decresaes the intensity, which is right. Squatting would initially increases venous return, contributing to a decrease in intensity. With prolonged squatting, you would additionally get an increase in afterload, which would additionally decrease the intensity.

Any my first aid doesn't even mention whether a worse murmur has a click closer to S1 or S2. It just says that it is loudest at S2, which makes sense since it is a crescendo murmur.

Basically, my FA somehow seems to correlate with what Goljan says.

The one thing that might be confusing is valsalva RELEASE. this phase you have an increase in blood flow back to the heart so an effective decrease in the intensity of MVP. As opposed to phase 2 of the valsalva, where you have an increased in intrathoracic pressure, decreasing venous return and thus increasing the intensity of MVP.
Click to expand...

Look at the errata dude
 
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MLT2MT2DO said:
There's a really solid explanation in the "difficult concepts thread". Someone did a good job of explaining the diff between prolapse and regurg in there.
Click to expand...

skyblue2000 said:
Awesome!! Thanks 🙂
Click to expand...

JP2740 said:
Look at the errata dude
Click to expand...

sharklasers said:
oh wow yeah their errata does look messed up my bad lol

should have known that considering you mentioend the errata in the topic title...
Click to expand...

UW q. ID: 947 supports what the original FA2013 said about MVP, but I read the paper cited from UW and it only left me more confused - something about decreased/increased duration instead of intensity. My exam is too close to care, tbh.
 
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