Approach to Cardiac Murmurs

Question 1

PMI

Answer 1

• PMI>2.5 cm evidence of LV hypertrophy from HT or Aortic stenosis
• Displacement lateral midclavicular line: LVH, MI, HF
• IN pt with COPD, PMI on xiphoid or epigastric area bc of RV hypertrophy

Question 2

Heart Sounds

Answer 2

S1: closure of the MV (LV P>LA P) S2: closure of AV (LV Pventricle)

Question 3

Split S2

Answer 3

• Wide Physiological Splitting: increase in usual split during inspiration caused by delay closing of PV or premature closing of AV
• Fixed splitting: doesn’t vary with respiration
• prolonged RV systole in Atrial septal defect or RV failure
• Reversed Splitting: appears on expiration and disappears in inspiration
• close of AV delayed so A2 follows P2 in expiration, and normal inspiratory delay of P2 makes the split disappear: caused by Left bundle branch block `

Question 4

Early Systolic Ejection Sounds

Answer 4

• after S1 bc of halting AV and PV as they open –> CVD -aortic ejection: both at base and apex-> dilated aorta, aortic valve disease, bicuspid aortic valve
• pulmonic ejection: 2nd and 3rd L ICS, S1 appears loud (should be soft), intensity decreased with inspiration–> dilation of pulm a, pulmon HT, pulmonic stensosis

Question 5

Systolic Clicks

Answer 5

• mitral valve prolapse: systolic ballooning of MV into LA
• Squatting: delays click and murmur due to increased venous return
• Standing: moves clicks closer to S1
• usually at apex but also at lower left sternal border, high-pitched
• followed by late systolic murmur from mitral regurg that crescendos up to S2

Question 6

Opening Snap

Answer 6

• very early diastolic sound caused by abrupt deceleration during opening of a stenotic MV
• heard medial to apex and along lower left sternal border high pitch snapping quality
• right after S2

Question 7

S3

Answer 7

• high LV filling pressures and abrupt deceleration of inflow across MV at end of rapid filling phase of diastole
• decreased myocardial contractility, heart failure, L-R shunts, ventricular vol overload

Question 8

S4

Answer 8

heard just before S1

-include hypertensive heart disease, aortic stenosis, ischemic and hypertrophic cardiomyopathy

Question 9

Systolic Murmurs

Answer 9

• aortic stenosis or sclerosis
• Benign tumor
• hypertrophic cardiomyopathy
• ventral septal defect
• tricuspid regurg
• MV prolapse
• Mitral insufficiency

Question 10

Diastolic Murmurs

Answer 10

• Right Upper or Left Midsternal Border: Aortic Insufficiency
• Left Upper sternal border: Pulmonic regurg
• Right Lower Sternal Border: Mitral stenosis
• Left lower sternal border: Tricuspid Stenosis

Question 11

Systolic Murmur Types

Answer 11

• Midsystolic: begins after S1 stops before S2, brief gaps between murmur or heart sounds
• Pansystolic: starts with S1 and stops at S2 without a gap between murmur and heart sounds
• Late Systolic Murmur: usually starts in mid or late systole and persists up to S2

Question 12

Diastolic Murmur Types

Answer 12

• Early: starts immediately after S2 without gap and fades into silence before next S1
• Middiastolic: starts shortly after S2, may fade away or merge into late diastolic murmur
• Late diastolic: starts late in diastole and typically continues up to S1

Question 13

Continuous Murmur

Answer 13

begins in systole and extends into all or part of diastole

Question 14

Crescendo/Decresendo Murmur

Answer 14

Crescendo: grows louder Decrescendo: grows softer Crescendo-Decrescendo: first rises in intensity, then falls Plateau: same intensity throughout

Question 15

Aortic Stenosis Murmur

Answer 15

-medium harsh, cresendo-decrescendo -Right 2nd and 3rd IC -Grade 4/6 or above

Question 16

Hypertrophic Cardiomyopathy Murmur

Answer 16

-Left 3rd and 4th ICS -Medium Pitch -Intensity decreased with squatting

Question 17

Pulmonic Stenosis Murmur

Answer 17

• Left 2nd and 3rd ICS
• Soft to loud

-Medium cresendo-decresendo

Question 18

Mitral Regurgitation

Answer 18

• Apex
• Soft to loud
• Medium to high
• Harsh holosystolic
• between S1 and S2
• intensity doesnt change with inspiration

Question 19

Tricuspid Regurg

Answer 19

• Lower left sternal border
• Variable intensity
• medium pitch
• blowing, holosystolic
• intensity increases with inspiration

Question 20

Ventricular Septal defect Murmur

Answer 20

• Left 3rd, 4th, 5th ICS
• Vry loud, with a thrill
• HIgh pitch, holosystolic

Question 21

Aortic Regurge Murmur

Answer 21

• Left 2nd and 4th ICS
• Grade 1-3
• High pitch
• Blowing decresendo
• Best heard with pt sitting and leaning forward

Question 22

Mitral Stenosis Murmur

Answer 22

• Limited to apex
• Descresendo low pitch rumnle with presystolic accentuation
• Listen with bell and turn pt to Lateral recumbent

Question 23

Maneuvers to ID Systolic murmurs

Answer 23

Squatting (increase vasc tone and LV vol):

MV Valve prolapse: decrease, delay of click ,murmur shorten

Hypertrophic Cardiomyopath: decrease intensity and outflow obstruction

Aortic Stenosis: increase blood vol & intensity

Standing (decrease vasc tone and LV vol):

MV Valve prolapse: increase prolapse, click moves earlier in systole and murmur lengthens

Hypertrophic Cardiomyopath: Increase intensity and outflow obstruction

Aortic Stenosis: decrease blood vol & intensity

Aortic Stenosis: increase blood vol & intensity