Cardiac Lecture - Stewart Flashcards
Aortic stenosis presentations
- OLD valves are SAD : Syncope, Angina, Dyspnea
- Crescendo-Decrescendo (letter A)
- Calcified aortic valve
- Radiates UP to Carotids
- Increased intensity with Squatting Valsalva
- Decreased intensity Standing Valsalva
major cause of Tricuspid Regurgitation
associated type of murmur
- TRIscuspid hit the most by IV drugs (venous- TRI Drugs)
2. Holosystolic/pansystolic/plateau murmur (continuos throughout systole)
Aortic Regurgitation characteristics
- Early blowing diastolic murmur
- Connective tissue disorders
- Marfan Syndrome
- Head-blobbing
- Femoral Bruits (backwash->turbulence)
- Water-Hammer Pulse
ARR, there she blows early!
pathology and location of systolic ejection murmur
heard during systole at the apex of heart (5th ICS on MCL).
Mitral valve Regurgitation
murmur due to blood going to where it’s not supposed to go (backflow)
Mitral Stenosis Pathology
- Opening Snap (soon after S2, during distal as ventricle begins to fill)
- Rheumatic fever history (Rheumitral)
- OS is MS
opening snap is Mitral stenosis
Mitral Valve Prolapse (MVP)
- midsystolic-click to S2 (crescendo)
- young woman with psychiatric issues (anxiety)
- Myxematous (tumor) Valvular Pathology (MVP)
the MVP clicks in the Mid-dle of nowhere!!
pathology of systolic murmur
mitral regurgitation
Mitral Regurgitation
- Rheu-mitral (rheumatic cardiac disease)
- Radiates to Axilla (regurgitates to armpit)
- Best heard at Apex (it’s closer to axilla)
- Holosystolic (plateau)
- Loud/blowing
S1 lower than S2… since valve doesn’t fully close.. usually higher
effect of inspiration on murmur
- louder Right heart side murmur (T&P loud)
- increases preload
- increases intrathoracic pressure
R-In
effect of expiration on murmur
- Left heart louder (M&A) (L-expiration)
increase in preload on aortic murmur in HOCM
decreases aortic murmur
more blood volume and pressure push the ventricular septum away from the aortic outflow allowing blood to move easily
decrease in preload on aortic murmur in HOCM
increases aortic murmur
less blood to push septum away from outflow track thus an obstruction and disruption of blood flow
increased preload in MVP
improves mid-systolic click
allows the prolapsed valve leaflets to return to their normal orientation
MVP valves orientation under normal pressure
mitral valve leaflets prolapse into L. atria under normal pressure and cause a disruption in blood flow
HOCM pathophysiology
type of murmur
- Loud aortic murmur
- small left ventricle due to thickened left ventricular septum
septum underwent hypertrophy to increase workload
MVP pathophysiology under normal pressure
-blood leaks back into left atrium due to mitral valve prolapse under normal pressure
MVP with regurgitation
HOCM presentation
intensity of murmur with squat and standing valsalva
family history of sudden cardiac death at a young age
louder with decreased preload and afterload (stand)
softer with increased preload and afterload (squat)
4 possible causes of systolic murmurs
Aortic stenosis
Pulmonary stenosis
Mitral regurgitation
Tricuspid regurgitation
+ HJR (Hepatic Jugular Reflux)
- poorly compliant RV, RV failure (failing to stretch so blood backflows easily)
- constrictive pericarditis
- obstructive RV filling due to RA tumor/ TS
+VE: Blood builds up in jugular and is visible as they distend and pulsate for a longer time
distension disappears sooner in a healthy heart –> heart increases outflow in response to increased blood volume
cause of Increased JVP
- SVC obstruction
- severe heart failure
- constrictive pericarditis, cardiac tamponade, RV infarction
V wave
Atrial filling / ventricular contraction
- increasing volume and pressure and RA when TV is closed
prominent V wave could mean
- TR (backflow of blood into atria increases pressure)
- pulm hypertension (increase RA due to back-pressure)
A wave
R. Atrial Contraction, TV opens. coincides with S1, precedes carotid pulsation
Giant A wave
- obstruction between RV AND RA (TV stenosis, RA myxoma)
- Increased RV pressure (pulmonary stenosis)
- recurrent pulm emboli
- pulmonary hypertension
- A-V dissociation (complete heart block, Ventricular Tachycardia)….(cannon a waves ) - RA contracts against the closed TV… In normal cases, Ventricle and A contraction shld be 1 after the other allowing TV to close and open but as long as there is no communication btwn the 2, there is continuous contraction on both ends while TV is closed
c wave
backwash push by closure of TV during isovolumetric systole and by impact of carotid artery adjacent to JV
X WAVE AND STEEP X WAVE
x-wave: passive atrial filling and atrial relaxation. blood flows into the RA from the cava and TV is closed
steep x: caridiac tamponade , constrictive pericarditis… making heart chamber unable to fully comply/stretch
y wave
deep Y CAUSE
slow Y
rapid ventricular filling - open TV –RV diastole
deep Y (low Y pressure): severe TR slow: obstruction to RV filling (TS/ RA myxoma)
S3
left atria fills the stiff, non-compliant left ventricle under high pressure
(LIKE trying to fill and already full ventricle)…more like applying brakes — failing ventricle
pathologic over 40 but physiologic in young chn/ young adults
Ken-Tuck-Y
S4
Ten-Nes-See
atrial filling sound due to high pressure from SVC/IVC and pulm venous return
Hypotension, CAD, old infarction
normal in athelets
loudest point of S1 and S2
S1: at the apex …Mitral valve (L.5th ICS at MCL)
S2: at the base (Aortic valve) right 2nd ICS at sternal border
remember base of heart is at the top
S1 marks beginning of systole s2: end
splitting of S2 happens during
Inspiration (physiologic)
due to increased VR during insp. and more time need for rv to deliver blood to the lung –delayed P2/p-closure
Tricuspid valve location
L. 4th ICS at L. Sternal Border
what grade do you start hearing thrills
grade 4-6
4 points to check pitting for edema
Behind medial malleolus
dorsum of foot
anterior tibia (shin)
sacrum
blunted diaphragms in a chest x-ray indicates
effusion
cause of pansystolic murmur on right and left
right
VSD
Tricuspid regurg
left
mitral valve regurg
cause of mid-late diastolic murmur (right and left)
right:
ASD
Tricuspid stenosis
left: mitral stenosis (presystolic crescendo)
left sternal border early diastolic murmur
aortic/pulmonic regurg
continuous murmurs
congenital and clinical conditions (not necessarily uniform but murmur is heard all the time)
Ebb’s point is best place to hear which murmur
aortic regurgitation - soft, high-pitched, early diastolic decrescendo
(btwn pulmonic and mitral valve)
best position to listen to AR and MS
AR: seated and leaning forward (ebb’s point)
MS: left lateral decubitus (apex, PMI , BELOW NIPPLE ) - belly of stetho
Late Systolic Murmur patient
healthy. non-pathological
Diastolic vs systolic murmur grades
diastolic - 4
systolic 6
both are easily heard at 3
no thrills in diastole
