52. Murmur

Question 1

Causes of murmurs?

Answer 1

Valvular heart disease (degenerative, rheumatic infective)

Prosthetic valves

Congenital heart disease

Functional murmurs (cardiomyopathies, LV dilation, aortic dissection)

Innocent murmurs (childhood, pregnancy)

Marfan’s syndrome

Infective endocarditis

Question 2

history taking murmur

Answer 2

PC:
HoPC: syncope on exertion/lightheadedness, palpitations, chest pain, hyperextension,
MHx: heart problems? autoimmune eg RA, SLE.
FH: early cardiac death (HOCM),
SHx: smoking, alcohol,

Question 3

invetsigation murmur

Answer 3

echocardiogram

Question 4

presentation symptomatic aortic stenosis

Answer 4

Exertional syncope (lightheadedness and fainting when exercising) due to difficulty maintaining a good flow of blood to the brain

chest pain
dyspnoea
syncope / presyncope (e.g. exertional dizziness)
palpitations

Question 5

o/e aortic stenosis

Answer 5

ass bump

murmur: ejection-systolic crescendo-decrescendo murmur

radiation: to carotids

pulse: slow rising pulse

other: narrow pulse pressure, thrill in aortic area

Question 6

causes of aortic stenosis

Answer 6

degenerative calcification (most common cause in older patients > 65 years)

bicuspid aortic valve (most common cause in younger patients < 65 years)

William’s syndrome (supravalvular aortic stenosis)
post-rheumatic disease
subvalvular: HOCM

Question 7

management aortic stenosis

Answer 7

if asymptomatic then observe the patient is a general rule
if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery

if symptomatic then valve replacement

Question 8

aortic stenosis interventions? how to pick?

Answer 8

options for aortic valve replacement (AVR) include:
- surgical AVR is the treatment of choice for young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combined

• transcatheter AVR (TAVR) is used for patients with a high operative risk

balloon valvuloplasty
- may be used in children with no aortic valve calcification
- in adults limited to patients with critical aortic stenosis who are not fit for valve replacement

Question 9

causes aortic regurgitation

Answer 9

valve disease chronic:
- rheumatic fever
- calcification
- connective tissue diseases eg RA, SLE
- bicuspid aortic valve

valve disease acute:
- infective endocarditis

aortic root disease chronic:
- bicuspid aortic valve
- spondyloarthropathies
- HTN
- syphillis
- Marfans, ehler-danlos syndrome

aortic root disease acute: - aortic dissection

Question 10

o/e arotic reguargitation

Answer 10

ard fall

murmur: early diastolic Switch back to the diaphragm, sit the patient forward and auscultate at the 4th/5th
intercostal space to the left of the sternum on held expiration

pulse: collapsing pulse (waterhammer),

other: wide pulse pressure

Question 11

what is pulse pressure

Answer 11

the difference between the systolic blood pressure and the diastolic pulse pressure

stroke volume/atrial compliance

Question 12

narrow pulse pressure vs wide pulse pressure

Answer 12

narrow pulse pressure if it is less than 25% of the systolic value

wide PP is >100mmHg difference

Question 13

causes narrow pulse pressure

Answer 13

most commonly causes by a drop in left ventricular stroke volume

• significant blood loss
• aortic stenosis
• cardiac tamponade

In the majority of these conditions, systolic pressure decreases, while diastolic pressure remains normal, leading to a narrow pulse pressure

Question 14

causes wide pulse pressure

Answer 14

exercise (systolic increase whilst diastolic drop reflects a reduced systemic vascular resistance of the muscle arterioles in response to the exercise)

increased stroke volume or decrease is systemic vascualr resistance

• distributive shock
• hyperthyroid
• aortic insufficiency:

Aortic regurgitation:
As the blood regurgitates back into the left ventricle during diastole, the diastolic pressure in the aorta decreases, thereby leading to an increase in the pulse pressure.

aortic dissection

Question 15

management of aortic regurgitation

Answer 15

medical management of any associated heart failure
surgery: aortic valve indications include
symptomatic patients with severe AR
asymptomatic patients with severe AR who have LV systolic dysfunction

Question 16

how does stenosis affect the heart muscle?

Answer 16

When pushing against a stenotic valve, the muscle has to try harder, resulting in hypertrophy:

Mitral stenosis causes left atrial hypertrophy
Aortic stenosis causes left ventricular hypertrophy

Question 17

how does regurgitation affect the heart muscle

Answer 17

When a leaky valve allows blood to flow back into a chamber, it stretches the muscle, resulting in dilatation:

Mitral regurgitation causes left atrial dilatation
Aortic regurgitation causes left ventricular dilatation

Question 18

presentation symptomatic mitral stenosis

Answer 18

malar flush

dyspnoea
↑ left atrial pressure → pulmonary venous hypertension

haemoptysis
due to pulmonary pressures and vascular congestion
may range from pink frothy sputum to sudden haemorrhage secondary to rupture of thin-walled and dilated bronchial veins

atrial fibrilation:
palpitations
stroke

Question 19

o/e mitral stenosis

Answer 19

msd u

murmur: mid- diastolic low pitched rumbing
Switch to the bell and auscultate the apex with the patient rolled 45° to the left

pulse: may have irregularly irregualr pulse (AF)

other: tapping apex beat, malar flush, atrial fibrilation

Question 20

causes mitral stenosis

Answer 20

RHEUMATIC FEVER

infective endocardititis
Rarer causes that may be seen in the exam include mucopolysaccharidoses, carcinoid and endocardial fibroelastosis

Question 21

cxr mitral stenosis

Answer 21

left atrial enlargement may be seen

Question 22

management mitral stenosis

Answer 22

treat AF with anticoagularion

asymptomatic: monitor with regualr echo

symptomatic:
- percutaneoius mitral baloon valvotomy
- mitral valve surgery

Question 23

presentation symptomatic mitral regurgitation

Answer 23

Most patients with MR are asymptomatic, and patients suffering from mild to moderate MR may stay largely asymptomatic indefinitely. Symptoms tend to be due to failure of the left ventricle, arrhythmias or pulmonary hypertension. This may present as fatigue, shortness of breath and oedema.

Question 24

o/e mitral regurgitation

Answer 24

mrs through

murmur: pan-systolic high pitched whistling murmur, radiate to axilla. third heart sound

pulse: Atrial fibrillation (irregularly irregular pulse)

Question 25

causes mitral regurgitation

Answer 25

Idiopathic weakening of the valve with age
Mitral valve prolapse
Ischaemic heart disease particualrly post-MI
Infective endocarditis
Rheumatic heart disease
Connective tissue disorders, such as Ehlers-Danlos syndrome or Marfan syndrome

Question 26

ecg mitral regurgitation

Answer 26

broad P wave, indicative of atrial enlargement

Question 27

management mitral regurgitation

Answer 27

Treat heart failure

In acute, severe regurgitation, surgery is indicated
The evidence for repair over replacement is strong in degenerative regurgitation, and is demonstrated through lower mortality and higher survival rates
When this is not possible, valve replacement with either an artificial valve or a pig valve is considered

Question 28

causes tricuspid regurgitation

Answer 28

right ventricular infarction
Pressure due to left-sided heart failure or pulmonary hypertension (“functional”)
rheumatic heart disease
infective endocarditis (especially intravenous drug users)
Ebstein’s anomaly
carcinoid syndrome

Question 29

o/e tricuspid regurgitation

Answer 29

mumur: pan-systolic murmur

other: prominent/giant V waves in JVP, pulsatile hepatomegaly, left parasternal heave

Question 30

genetics marfans

Answer 30

autosomal dominant connective tissue disorder. It is caused by a defect in the FBN1 gene on chromosome 15 that codes for the protein fibrillin-1.

Question 31

features marfans

Answer 31

tall stature with arm span to height ratio > 1.05
high-arched palate
arachnodactyly
pectus excavatum
pes planus
scoliosis of > 20 degrees
Joint hypermobility: Patients with Marfan’s syndrome often exhibit increased joint flexibility, predisposing them to dislocations and early-onset osteoarthritis.

heart:
dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm, aortic dissection, aortic regurgitation
mitral valve prolapse (75%),

lungs: repeated pneumothoraces

eyes:
upwards lens dislocation (superotemporal ectopia lentis)
blue sclera
myopia

dural ectasia (ballooning of the dural sac at the lumbosacral level)

Question 32

heart marfans

Answer 32

dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm, aortic dissection, aortic regurgitation
mitral valve prolapse (75%),

Question 33

lungs marfans

Answer 33

repeated pneumothoraces

Question 34

eyes marfans

Answer 34

upwards lens dislocation (superotemporal ectopia lentis)
blue sclera
myopia

retinal detachment
glaucoma and cataracts

Question 35

o/e marfans cardio exam

Answer 35

inspection:
- hands: arachnodactyly
- mouth : high arched palate
- chest: pectus excavatum

auscultation:
aortic regurgitation (due to dialtion of aortic root)
murmur: early diastolic Switch back to the diaphragm, sit the patient forward and auscultate at the 4th/5th
intercostal space to the left of the sternum on held expiration
pulse: collapsing pulse (waterhammer),

OR mitral valve prolapse –> mitral regurgitation
murmur: pan-systolic high pitched whistling murmur, radiate to axilla. third heart sound

Question 36

what medications can help ppl with marfans

Answer 36

ACEi, beta blockers

Question 37

chromosome marfans

Answer 37

15

Question 38

what is a cardiomyopathy?

Answer 38

Cardiomyopathy is a term used to describe a heart muscle disorder, without another obvious cardiac abnormality.

myocardial disorder in which heart muscle is structurally and functionally abnormal without coronary artery disease, hypertension, valvular or congenital heart diseases.
However, sometimes cardiomyopathy is a result other cardiac disease, such as hypertension, valvular disorders or ischaemic heart disease.

Question 39

what type of cardiomyopathy may have an associated murmur? what murmur

Answer 39

hypertrophic obstructive cardiomyopathy (HOCM)

ejection systolic - DOES NOT RADIATE TO CAROTIDS

Question 40

prevelance of HOCM

Answer 40

1 in 500

Question 41

genetic HOCM

Answer 41

Autosomal dominant genetic disorder – but has variable penetrance and expressivity
A mutation in any one (or more) of up to 12 genes that code for cardiac proteins can cause the disease
Troponin T mutations are the most significant. They are more likely to cause sudden cardiac death and often this occurs without any left ventricular hypertrophy (LVH)

Question 42

pathophysiology HOCM

Answer 42

left ventricle hypertrophy → decreased compliance (filling during diastole)→ decreased cardiac output

–> left ventricualr outlet obstruction

–> mitral regurgitation

–> Arrhythmogenesis: Myocardial disarray, fibrosis, and ischemia increase the risk of ventricular and atrial arrhythmias, which can lead to sudden cardiac death.

Question 43

presentation HOCM

Answer 43

Most cases are asymptomatic
Dyspnoea
Chest pain
Syncope (especially on exercise)
Both syncope and dyspnoea may be initiated by alcohol
Always investigate unexplained syncope in young athletes
Palpitations
Family history of HCM

Question 44

what causes sudden death in HOCM

Answer 44

Can be due to arrhythmia or due to outflow tract obstruction

Unexplained syncope is a risk factor for sudden death

Question 45

o/e HOCM

Answer 45

can be normal

murmur: Late ejection systolic murmur exacerbated by valsalva manoeuvre, reduced when squatting
Does NOT radiate to the neck
Best heard at left sternal edge, 3rd-4th intercostal space

pulse: atrial fibrilation Occurs in 20% of patients

other: prominent JVP a wave, abnormal blood pressure response to exercise, foreceful apex beat

Question 46

management HOCM

Answer 46

Reduce outflow tract obstruction gradient, and improve diastolic function
1. Beta-blcokers, Verapmil
2. surgical myomectomy to reduce the outflow tract obstruction (septal myectomy, alcohol septal ablasion)

If needed = anti-arrythmia
1. Disopyramide
2. Implantable cardioverter defibrillator should be consider for those at high risk of sudden death

+anticoagulation if AF
+Avoidance of competitive sports and strenuous exercise

Question 47

what drugs should you be careful of in HOCM

Answer 47

BEWARE of drugs that reduce preload, as these decrease the chamber size and exacerbate symptoms. These include:
ACE inhibitors, ARBs, nitrites and diuretics
This is a major difference between management of DCM and HCM

Question 48

why are Beta-blcokers and Verapmil used in HOCM

Answer 48

These drugs reduce cardiac contractility, and thus dilate the hypertrophied left ventricle, reduce outflow tract obstruction and improving diastolic function
These drugs improve the physical functioning of the heart muscle but do not have a significant effect on arrhythmias

Question 49

how to differentiate aortic stenosis from HOCM mumrur

Answer 49

AS
- radiate to carotids
- murmur worse on squatting as it increases pre-load

HOCM
- no radiation to carotids
- murmur worse on valsalva as it decreases pre-load