all heart sounds and murmurs Flashcards
cause of heart sounds in general
turbulent blood flowtensing of cardiac structuresvalve closure
cause of S1 heart sound
AV (tricuspid and mitral) valve closure
what phase of cardiac cycle is S1
start of systole - isovolumic contraction
phases of the cardiac cycle
isovolumic contraction - period between which AV valves shut, SL valves open; ventricles contracting in a closed circuit
rapid ejection - opening of SL valves; c wave in JVP
reduced ejection - slowing of ejection ultimately causing closure of SL valves (aortic and pulmonary trunk pressures >ventricular pressure)isovolumic relaxation - relaxation of ventricles when both AV and SL valves are shut; V wave in JVPrapid ventricular filling - AV valves open causing rapid filling; y descent in jvpdiastasis - as filling of ventricles nears ~80%atrial systole - atria contract to top of the ventricles with last amount of blood; a wave in jvp
cause of S2 heart sound
SL (pulmonary and aortic) valve closure
what phase of cardiac cycle is S2
end of systole/beginning of diastole - isovolumic relaxation
cause of S3 heart sound
volume overload
tensioning of chordae tendinae at the end of rapid ventricular filling
sudden deceleration of blood against LV
cause of S4 heart sound
pressure overload
reflection of atrial wave against a poorly compliant ventricle (thickened or stiff)
pathologies where S4 is seen
LV hypertrophy secondary to HTN
aortic stenosis,acute MR
IHD, age +++
angina, MI sometimes - only thing seen acutely
pathologies where S3 is seen
normal in young people and athletes
in older people - congestive heart failure
physiological - thyrotoxicosis, pregnancy
symptoms of MS
dyspnea, orthopnea, PND - increased left atrial pressure
hemoptysis - ruptured bronchial veins
ascites, edema, fatigue - pulmonary HTN, decrease CO
signs of MS
mitral facies
peripheral cyanosis
pulse of MS
normal or reduce in volume - reduced CO
AF may be caused if left atrial enlargement
JVP in MS
normal height
prominent a wave if pulmonary HTN present
loss of a wave if AF
palpation in MS
tapping apex beat
RV heave
palpable P2
auscultation in MS
T/C - mid diastolic low pitched rumbling diastolic murmur
R - nil
loud S1 - valve cusps remain wide open at onset of systole
loud or palpable P2 if pulmonary HTN
opening snap - high LA pressure forces valve open
accentuation manoeuvres in MS
exercise
left lateral position
causes of MS
RHD
congenital parachute valve
MR symptoms
dyspnea - increased LA pressure
fatigue - decreased CO
MR signs
tachypnea
MR pulse
normal or sharp upstroke due to rapid ventricular decompression
AF relatively common
JVP in MR
n/a
palpation in MR
displaced, diffuse and hyperdynamic apex beat
pansytolic thrill occasionally present at apex
parasternal heave due to LA enlargement behind the RV
auscultation in MR
T/C - pansytolic murmur maximal at apex and usually radiating towards axilla
soft or absent S1-
LV S3 due to rapid LV filling in early diastole
MR accentuation manoeuvres
valsalva - longer and louder
causes of MR
mitral valve prolapse
degeneration associated with age
RHD
papillary muscle dysfunction due to LV failure or ischemia
cardiomyopathy - hypertrophic, dilated or restrictive
CT diseases
congenital
AR symptoms
occurs in late stage of disease
exertional dyspnea, fatigue, exertional angina - decreased CO
palpitations - hyperdynamic circulation
AR signs
none specifically but
marfanoid features
Ankolysing spondylitis or other seronegative arthropathies
AR pulse and BP
collapsing pulse ‘water hammer’ - most obvious if raising patient’s arm while feeling radial pulse
wide pulse pressure - DBP very low as leaking back constantly, SBP normal
bisfiriens pulse - severe AR - venturi effect - rapid ejection and brief in drawing of aortic wall leading to a diminution of the pulse followed by rebound increase
AR JVP/neck
prominent carotid pulsations
AR palpation
displaced and dyskinetic apex beat
diastolic thrill may be felt at LSE if sitting up and exhaling
AR auscultation
T/C - early diastolic, decrescendo quality, high pitched. may extend for variable time into diastole
loudest at 3/4 ICS
soft A2 component
systolic ejection murmur usually also present - aortic stenosis or turbulent flow across normal diameter aortic valve
AR accentuation manouvres
expiration and leaning forward
acute AR causes
valvular - IE
aortic root - marfan’s syndrome - aortic dissection
chronic AR causes
valvular RHD (rarely the only murmur if so) congenital (bicuspid valve, VSD) seronegative arthropathy esp ankolysing spondylitis aoritc root dilation marfan's aortitis rheumatoid arthritis teritary syphilis dissecting aneurysm
differentiate acute AR to chronic AR
acute - no collapsing pulse (BP is low) and diastolic murmur is short
AS symptoms
exertional chest pain (50% no CAD)
exertional dyspnea and exertional syncope
AS signs
usually nothing remarkable
AS pulse
plateau pulse (anacrotic) OR late peaking and low volume (tardus et parvus)
AS JVP
n/a
AS palpation
hyperdynamic apex beat
may be slightly displaced
systolic thrill at base of heart (in aortic area)
AS auscultation
T/C - harsh (mid)systolic ejection murmur, crescendo - decrescendo
R - maximal over aortic area and extending into carotids, may extend widely over precordium and extend to apex
narrowly split or reversed S2 - delayed LV ejection
AS accentuation manouvres
sitting up and in full expiration
note - associated aortic regurg is common
AS causes
degenerative calcific aortic stenosis - elderly
calcific in younger patients - congenital bicuspid valve
rheumatic
