62. Abnormal Heart Sounds and Murmurs Flashcards
Murmurs and abnormal heart sounds may be detected on physical examination. Although systolic murmurs are often "innocent" or physiological, diastolic murmurs are virtually always pathologic. A thorough history and physical examination almost always identifies which patients require further investigation and management.
Which are the heart sounds
Ventricular systole: Between S₁-S₂
S₁: Mitral and Tricuspid closure (M₁+T₁)
S₂: Aortic and Pulmonic closure (A₂+P₂)
Type of Heart Murmurs
▸Accurate timing is the first step in their identification.
▸Systolic murmur: Begins with/after S₁ and end at/before S₂
▸Diastolic murmur: Begins with/after S₂, and end at/before S₁
▸Continuous murmur: Begin in early systole and proceed through S₂ into all or part of diastole
In what depend the murmur duration?
On length of time over which a pressure difference exists between: ▸Two cardiac chambers ▸LV and Aorta ▸RV and Pulmonary artery ▸The great vessels
Intensity
▸Can be diminished with ↑ distance heart and stethoscope (obesity, EPOC, large pericardial effusion)
▸Grades:
▹I: Very soft and heard only with great effort.
▹II: Easily heard but not loud.
From here, there is an important structural disease
▹III: Loud but no palpable thrill (vibration) over the site of maximal intensity
▹IV: very loud + thrill
▹V: loud enough to be heard with only edge of stethoscope touching the chest.
▹VI: loud enough to be heard with stethoscope slightly off the chest.
Location and radiation of chest areas and sound characteristics
▸Aortic area: Right 2nd intercostal space, sternal border, radiates to carotides.
▸Pulmonic area: Left 2nd intercostal space, sternal border
▸Tricuspid area: Left 5th intercostal space, sternal border
▸Mitreal area: Left 5th intercostal space, midclavicular line, radiates to armpit
▸Regurgitation: Blowing sounds
▸Stenosis: Liquid trying to scape
Systolic heart murmurs
Types
▸Early systolic murmur: Begin with S₁,end before S₂
▹Origin: Mitral, Ventricular Septal Defect (VSD), Tricupsid
▸Mid-systolic murmurs: Begins right after S₁, end before S₂
▹Origin: Aortic, Pulmonary (Grade I-II normal in Pregnancy, Anemia)
▸Late systolic murmur: Best heard at Left Ventricular apex
▹Origin: Mitral, Tricuspid
▸Holosystolic murmur: Begins with S₁ and continue through systole to S₂
▹Causes: Chronic mitral or Tricuspid regurgitation or VSD
Diastolic heart murmurs
Types
▸Early diastolic murmur: Begins with S₂, end before S₁
▹AR, PR
▸Mid-diastolic murmurs: Result from obstruction and/or ↑flow in mitral or tricuspid valve
▹Origin: Mitral and Tricuspid
▹Causes: Rheumatic fever (MCC of MS), Atrial tumors
Continuous murmurs
▸Begin in systole, peak near S₂, continue into all or part of diastole.
▸Not all are pathologic (Children, Young adults, pregnancy)
Differentiating Heart Murmurs
▸Innocent: ▹Grade: <3 ▹Extra sound/clicking: None ▹Change of position: Murmur varies ▸Pathological: ▹Grade: ≥3 ▹Extra sound/clicking: May be present ▹Change of position: Unchanged
Mitral Stenosis (MS) Facts
▸MCC Rheumatic fever (thickened mitral valve leaflets, fused commisures, chordae tendineae)
▸May cause RV failure
▸2/3 are female
Mitral Stenosis (MS) Pathogenesis
▸↓LV filling
▸↑LA pressure referred to the lungs →Pulmonary congestion→RV failure
Mitral Stenosis (MS) Clinical Features
▸Dyspnea on exertion
▸Huge LA (Dysphagia, AF)
▸S₁ loud, opening snap following S₂
Mitral Stenosis (MS) Diagnosis
▸ECG: May ↑RV and Atrial Fibrillation ▸CXR: ▹↑LA (double-density right heart border, posterior displacement of esophagus) ▹May pulmonary HTN (Jerley B lines + vascular markings) ▸Echocardiography; ▹↑Thick mitral valve ▹↓area of valve leaflets ▹↑LA
Mitral Stenosis (MS) Tx
▸Medical:
▹↓Preload (Diuretics + ↓NaCl)
▹If AF: Digitalis + Anticoagulants
▸Qx:
▹If px remains symptomatic with medical tx (function class III)
▹Valve replacement or Mitral commissurotomy
Mitral Regurgitation (MR) Definition
▸Backflow of blood from LV to LA due to insufficiency of Mitral valve
▸> male
▸Mitral Valve Prolapse (MCC)
▸Ischemic Heart Disease (2º MCC)
Mitral Regurgitation (MR) Pathogenesis
▸MR⇒↓CO⇒↑LA+↑LV pressure⇒LA+LV dilatation⇒Pulmonary HTN⇒CHF
Mitral Regurgitation (MR) Clinical Features
▸Holosystolic murmur radiation to armpit ▸LV Failure symptoms: ▹Dyspnea, Orthopnea, Paroxysmal Nocturnal Dyspnea ▸Displaced hyperdinamic apex ▸Distended neck veins ▸Holosystolic murmur radiation to armpit
Mitral Regurgitation (MR) Dx
▸ECG: ↑LV+↑LA (if chronic)
▸CXR: Cardiac enlargement, Pulmonary HTN
▸Echocardiography: Mitral valve can prolapse into LA in systole when ruptured chordae
▸Catheterization: Large V wave (due to systolic volume overload on LA)
Mitral Regurgitation (MR) Tx
▸Asymptomatic: serial echos
▸Symptomatic:
▹ACEI + Anticoagulants
▹If CHF: Diuretics and Digitalis
▸Qx: before heart starts to dilate because is irreversible
▹Mitral Valve replacement when limiting symptoms and severe mitral regurgitation
Mitral Valve Prolapse (MVP)
Definition
▸Mitral valve displaced into LA during systole
▸Congenital (MCC)
▸Most typically in young female + connective tissue disease (Marfan, Ehler Danlos, or idiopathic)
Mitral Valve Prolapse (MVP)
Clinical Features
▸Mid-systolic click (pathognomonic)
▸mid to late systolic murmur at apex
▸Worsen with Valsalva or squatting (cuclillas)
▸Only valvulopathy with chest pain
Mitral Valve Prolapse (MVP)
Dx
▸Echocardiography: Systolic displacement of mitral valve into LA
Mitral Valve Prolapse (MVP)
Tx
▸Asymptomatic: No tx
▸Symptomatic:
▹β-blockers, avoid stimulants (caffeine)
▹If AF ⇒ Anticoagulation
▸Qx: if symptomatic + significant MR = Mitral Valve Replacement
Aortic Stenosis (AS) Definition
▸Calcification and degeneration of normal valve.
▸Age (elder) (MCC)
▸Congenital (bicuspid, unicuspid valve) (2º MCC)
▸Rheumatic disease (same effect as in MS, if Aortic is affected)
Aortic Stenosis (AS) Classification by valve area
▸Normal: 3-4 cm² ▸Mild AS: 1.5-3 cm² ▸Moderate AS: 1-1.5 cm² ▸Severe AS: 0.5-1 cm² ▸Critic AS: <0.5 cm²
Aortic Stenosis (AS) Pathophysiology
▸Outflow obstruction⇒↑LV pressure⇒LV hypertrophy⇒LV failure⇒CHF, subendocardial ischemia
Aortic Stenosis (AS) Clinical Features
▸Sound: Crescendo-decrescendo murmur radating to carotids ▸Angina (most common), syncope ▸CHF (worst prognosis) ⇒ give diuretics ▸Pulsus tardus et parvus ▸Carotid thrill
Aortic Stenosis (AS) Dx
▸ECG: LV hypertrophy
▸CXR: Calcification, Cardiomegaly and Pulmonary Congestion
▸Echocardiography: Reduced valve area
Aortic Stenosis (AS) Tx
▸Asymptomatic: Echos, avoid exertion
▸Symptomatic:
▹NO ARTERIAL DILATORS (NITRATES) and ACEI
▹If CHF ⇒ Diuretics
▸Qx: Valve replacement
▹If too ill to tolerate Qx ⇒Balloon valvuloplasty
Aortic Regurgitation (AR) Causes
▸Anything that makes aorta or heart to dilate
▹Systemic HTN (MCC)
▹Marfan’s Syndrome
▹After infectious endocarditis
Aortic Regurgitation (AR) Physiopathology
AR⇒LV volume overload⇒LV dilation⇒↑stroke volume⇒↑wall tension⇒pressure overload⇒LV hypertrophy
Aortic Regurgitation (AR) Clinical Features
▸Blowing decrescendo murmur, midsystolic flow murmur
▸Austin Fling: mid to late diastolic rumble
▸Duroziez’s sign: Diastolic thrill or murmur heard over the femoral arteries
▸Wide pulse pressure, water hammer (bounding) pulse
▸Musset’s Sign: rhythmic nodding or bobbing of the head in synchrony with the beating of the heart
Aortic Regurgitation (AR) Dx
▸ECG: LV hypertrophy ▸CXR: LV and Aortic Dilation ▸Echo: ▹Dilated LV + Aorta ▹LV volume overload
Aortic Regurgitation (AR) Tx
▸Asymptomatic: Echos, ↓afterload (ACEI, nifedipine, hydralazine), ↓NaCl, diuretics
▸Symptomatic: + avoid exertion
▸Qx: Aortic valve replacement when symptoms worsen or EF <50%
Tricuspid Stenosis (TS) Pathophysiology
TS⇒↑RA pressure⇒Right heart failure⇒↓CO
Tricuspid Stenosis (TS) Clinical Features
▸Prominent “a” waves in JVP
▸Kussmaul’s sign (paradoxical rise in JVP on inspiration)
▸Diastolic rumble in 4th left intercostal space
Tricuspid Stenosis (TS) Dx
▸ECG: RA enlargement
▸CXR: dilation of RA without pulmonary artery enlargement
▸Echo: DIAGNOSTIC
Tricuspid Stenosis (TS) Tx
▸↓Preload (diuretic)
▸Qx: Only if required (mitral valve replacement)
Tricuspid Regurgitation (TR) Pathophisiology
RV dilation (Etiology)⇒TR⇒Further RV dilation⇒Right heart failure
Tricuspid Regurgitation (TR) Clinical Features
▸”cv” waves in JVP
▸Kussmaul’s sign (paradoxical rise in JVP on inspiration)
Tricuspid Regurgitation (TR) Dx
▸ECG: RA enlargement, AF
▸CXR: dilation of RA
▸Echo: DIAGNOSTIC
Tricuspid Regurgitation (TR) Tx
▸↓preload (diuretics)
▸Qx: only if required (mitral valve replacement)
Pulmonary Stenosis (PS) Etiology
▸Usually congenital
Pulmonary Stenosis (PS) Pathophysiology
▸↑RV pressure⇒RV hypertrophy⇒Right heart failure
Pulmonary Stenosis (PS) Clinical Features
▸Systolic murmur at 2nd left intercostal space accentuated by inspiration
Pulmonary Stenosis (PS) Dx
▸ECG: RV hypertrophy
▸↑pulmonary arteries and ↑RV
▸Echo: DIAGNOSTIC
Pulmonary Stenosis (PS) Tx
▸Balloon valvuloplasty if severe symptoms
Pulmonary Regurgitation (PR) Etiology
▸Pulmonary HTN
▸Tetralogy of Fallot (post-repair)
Pulmonary Regurgitation (PR) Pathophysiology
↑RV volume⇒↑wall tension⇒RV hypertrophy⇒Right heart failure
Pulmonary Regurgitation (PR) Clinic Fetures
▸Graham Steell (diastolic) murmur at 2º left intercostal space with full inspiration
For all Valvular Heart Diseases
Best initial test
▸2D echo (TTE, then TEE)
For all Valvular Heart Diseases
Most accurate test
▸Angiography
For all Valvular Heart Diseases
Symptoms
▸All have no specific symptoms ▹SOB ▹Fatigue ▹Rales (estertores) ▹Dyspnea
Preload maneuvers
Increase Preload
▸Leg raising and Squatting (cuclillas) ▹↑venous return ▸Murmur ↑ intensity (AS, AR, MS, MR) ▸Murmur ↓ intensity (HOCM*, MVP) *Hypertrophic Obstructive Cardiomiopathy
Preload maneuvers
Decrease Preload
▸Standing, Valsalva
▹↓venous return
▸Murmur ↑ intensity (HOCM, MVP)
▸Murmur ↓ intensity (AS, AR, MS, MR)
Afterload maneuvers
Decrease Afterload
▸Amyl nitrate
▹↓blood in ventricle
▸Murmur ↑ intensity (AS, MS, HOCM, MVP)
▸Murmur ↓ intensity (AR, MR, VSD)
Afterload maneuvers
Increase Afterload
▸Hand grip
▹↑blood in ventricle
▸Murmur ↑ intensity (AR, MR, VSD)
▸Murmur ↓ intensity (AS, MS, HOCM, MVP)
