Cardiac Murmurs

Question 1

Innocent murmurs

Answer 1

Characteristics of an innocent ejection murmur include:
-soft-blowing murmur in the pulmonary area or
-short buzzing murmur in the aortic area
-may vary with posture
-localised with no radiation
-no diastolic component, diastolic is not innocent
-no thrill
-no added sounds (e.g. clicks)
-asymptomatic child
-no other abnormality

Innocent murmurs heard in children include

1. Ejection murmurs
   Due to turbulent blood flow at the outflow tract of the heart
2. Venous hums
   Due to the turbulent blood flow in the great veins returning to the heart. Heard as a continuous blowing noise heard just below the clavicles
3. Still’s murmur
   Low-pitched sound heard at the lower left sternal edge

Question 2

Congenital heart disease: types

Answer 2

Cyanotic - most common causes
-TOF tetralogy of Fallot
-TA tricuspid atresia
-TGA transposition of the great arteries (TGA)

Overall TOF more common than TGA but at birth TGA is the more common than TOF

Acyanotic - most common causes
-ASD atrial septal defect (ASD)
-VSD ventricular septal defects (VSD) - most common, accounts for 30%
-PDA patent ductus arteriosus (PDA)
-COA coarctation of the aorta
-AS aortic valve stenosis

VSDs are more common than ASDs. However, in adult patients ASDs are the more common new diagnosis as they generally presents later

Question 3

Murmurs

Answer 3

Systolic:
-Ejection systolic
-Holosystolic (pansystolic)
-Late systolic

Diastolic:
-Early diastolic
-Mid-late diastolic

Ejection systolic:
-Louder on expiration:
–AS-aortic stenosis
–HOCM-hypertrophic obstructive cardiomyopathy

-Louder on inspiration:
–Pulmonary stenosis
–Atrial septal defect
also: tetralogy of Fallot

Holosystolic (pansystolic): MR, TR, VSD
-Mitral/Tricuspid regurgitation (high-pitched and ‘blowing’ in character)
–tricuspid regurgitation: louder during inspiration, unlike mitral reguritation
-Ventricular septal defect (‘harsh’ in character)

Late systolic: MVP. COA
-Mitral valve prolapse
-Coarctation of aorta

Early diastolic: AR, PR
-Aortic regurgitation (high-pitched and ‘blowing’ in character)
-Graham-Steel murmur (pulmonary regurgitation, again high-pitched and ‘blowing’ in character)

Mid-late diastolic:
-Mitral stenosis (‘rumbling’ in character)
-Austin-Flint murmur (severe aortic regurgitation, again is ‘rumbling’ in character)

Continuous machine-like murmur: PDA
-Patent ductus arteriosus

RILE
Right-sided murmur → heard best on Inspiration
Left-sided murmur → heard best on Expiration