3. Which of these can increase the intensity of the murmur of mitral valve regurgitation?

A. Squatting from a standing position

B. Valsalva maneuver

C. Transient arterial occlusion or handgrip exercises

D. Amyl nitrate inhalation

Handgrip exercises and transient arterial occlusion increase the murmur of mitral regurgitation.

Handgrip exercises, performed by having the patient squeeze both hands intensely for at least one minute, increases afterload. When the afterload is increased, there is more resistance to blood flow from the left ventricle through the aortic valve, and thus more blood regurgitates through the mitral valve.

Transient arterial occlusion, or TAO, is performed by inflating blood pressure cuffs on both arms to increase the afterload. This has the same effect on the murmur of mitral regurgitation as handgrip exercises and may be the preferred method if a patient is not able to adequately perform a strong handgrip.

Amyl nitrate decreases afterload and would decrease the murmur of mitral regurgitation. When the afterload is decreased, there is less resistance to blood flow from the left ventricle through the aortic valve, and thus less blood regurgitates through the mitral valve, decreasing the intensity of the murmur.