Cardiac Murmurs

Question 1

Which murmurs radiate?
Which must be accentuated?
When are murmurs on each side best heard?

Answer 1

Systolic => radiate
Diastolic => accentuated
Left => expiration
Right => inspiration

Question 2

Aortic stenosis
-best heard, radiation
-pathology
-signs
-causes
How does this differ from aortic sclerosis

Answer 2

Ejection systolic with/without S2
RSE => carotids
Decreased with Valsalva

Stops carotid outflow => limited CO => LVH

Slow rising pulse, narrow BP
Heaving apex beat
Quiet S2, (S4)

Calcification - 65+
bicuspid aortic valve - U65
William's syndrome (supravalvular aortic stenosis)
post-rheumatic disease
subvalvular: HOCM

No radiation as valves have thickened, not narrowed
-no abnormal signs

Question 3

Mitral regurgitation
-best heard, radiation
-pathology
-signs
-causes
How does this differ from mitral prolapse

Answer 3

Pansystolic
Apex => axilla

Regurg to LA => LA dilation => LV dilation => LVF => pul edema

Displaced apex
Soft S1, S3 due to LVF
P HTN => loud P2
Heave (LVD)
AF (LAD)

Papillary muscle disfunction post MI
DCM
Rheumatic
Endocarditis
Congenital

Mid systolic click as valve prolapses back
-often congenital connective tissue disorder related

Question 4

Ventricular septal defect

• best heard, radiation
• pathology
• signs
• causes

Answer 4

Pansystolic

Lower LSE

In systole, some blood from LV leaks into RV

If small, none

Loud P2

COngenital

Question 5

Tricuspid regurgitation
-best heard, radiation
-pathology
-signs
-causes
How does this differ from mitral regurgitation

Answer 5

Pansystolic
Lower LSE

Regurgitation to RA => systemic backflow

Large JVP, pulsatile liver, heaves (RVH)

Cor pulmonale
Infective endocardiditis in IVDU

Louder in inspiration, JVP, non displaced apex

Question 6

Mitral stenosis

• best heard, accentuation
• pathology
• signs
• causes

Answer 6

Mid diastolic, opening snap
Apex on left side

High LA pressure
PHTN
RHF

Malar flush (due to low CO
AF
Loud S1
PHTN (Loud P2, RVheave)

Rare (rheumatic)

Question 7

Aortic regurgitation

• best heard, accentuation
• pathology
• signs
• causes

Answer 7

Early diastolic, breathlike

Upper RSE

Systemic backflow

Collapsing pulse
Wide pulse pressure
Displaced apex
Backflow signs
-Corrigan's - visible carotid pulsation
-de Musset's  - head nodding
-Quinke's - red pulsation in nails
-Austin Flint - apical diastolic rumble

Acute
-infective endocarditis
-aortic dissection
Chronic
-connective tissue disorders

Question 8

Pulmonary regurgitation

• best heard, accentuation
• pathology
• signs
• causes

Answer 8

Decresc murmur in early diastole

Upper LSE

Pulmonary backflow

RVH

Anything that causes PHTN