Cardiac murmurs Flashcards
Name five systolic murmurs.
Aortic stenosis, Miral regurgitation, ventricular septal defect, mitral valve prolapse, HOCM
Name the two main diastolic murmurs.
Aortic regurgitation, Mitral stenosis
Explain the algorithm for deciphering aortic valvular murmurs on an aortic/LV pressure tracing.
If LV pressure is increased above 120 mm Hg, it has to be an aortic valve problem (stenosis or insufficiency). If a pressure gradient exists between the LV and aortic pressures (i.e. the aortic pressure is much lower than the increased LV pressure), it is AORTIC STENOSIS. If aortic pressure is raised with LV pressure and no gradient exists, it is AORTIC INSUFFICIENCY.
<p>Explain the algorithm for deciphering mitral valvular murmurs on an atrial pressure tracing.</p>
<p>LV pressure will be NORMAL.
Will see an increase in left atrial pressure for both mitral stenosis and regurgitation.
If increase in LA pressure occurs during diastole, it is MITRAL STENOSIS.
If increase in LA pressure occurs during systole, it is MITRAL REGURGITATION.</p>
What happens to EDV in mitral stenosis?
Decreases due to decreased ventricular filling.
What happens to EDV in mitral regurgitation?
Increases, because the elevated pressure within the left atrium is eventually transmitted to the left ventricle during filling.
Which murmur commonly radiates to the axilla?
Mitral regurgitation
Which murmur commonly radiates to the right sternal border?
Tricuspid regurgitation
Where does the murmur of mitral regurgitation commonly radiate?
Axilla
What will inspiration do to a tricuspid regurgitation murmur?
Increase
Mitral regurtitation murmurs are typically of what quality (audibly)?
Holosystolic, high pitched, “blowing”
Tricuspid regurtitation murmurs are typically of what quality (audibly)?
Holosystolic, high pitched, “blowing”
Describe the murmur of VSD
Holosystolic, HARSH sounding murmur. Loudest at tricuspid area, accentuated with handgrip maneuver due to increased afterload.
Inspiration will have what effect on heart murmurs?
Increase all right sided murmurs (except pulmonary ejection click)
Expiration will have what effect on heart murmurs?
Increase all left sided murmurs
What does prolonged hand grip do to hemodynamics?
Increases systemic vascular resistance
What is physiologic splitting of S2?
S2 splits on inspiration.
What causes physiologic splitting of S2?
Inspiration causes a drop in intrathoracic pressure, increasing venous return to RV, causing increased RV stroke volume, causing the pulmonic valve to close after the aortic.
What causes fixed splitting of S2?
ASD (due to high RA and RV volumes secondary to a R–>L shunt)
What is paradoxical splitting of S2?
Splitting of S2 on expiration
What causes paradoxical splitting of S2?
Left bundle branch block, aortic stenosis. These result in delayed or prolonged LV emptying, resulting in aortic valve closure after the pulmonary valve.
What does a Valsalva maneuver do to hemodynamics?
Decreases venous return to the right side of the heart, decreasing preload.
What is the auscultatory hallmark of an ASD?
Fixed splitting of S2
What causes S3?
Volume overload during early rapid ventricular filling
When is an S3 heard in the cardiac cycle?
Right after S2, in early diastole
What causes S4?
Atrium contracting against a stiffened ventricle
When is an S4 heard in the cardiac cycle?
Right before S1, in late diastole
What does inspiration do to hemodynamics?
Increases venous return to the right side of the heart, increasing volume/flow.
What effect does squatting have on hymodynamics?
Increases venous return, preload, and afterload
What effect does going from standing to squatting have on hemodynamics?
Increases venous return, preload, and afterload
What does amyl nitrate do to hemodynamics?
Decreases TPR (vasodilation)
What effect do vasopressors have on hemodynamics?
Increase TPR (vasoconstriction)
At what grade of murmur is a thrill first palpable?
4
What is a pansystolic (holosystolic) murmur?
A systolic murmur that has an intensity that does not change.
What are the only three holosystolic (pansystolic) murmurs?
MR, TR, VSD
Which murmur has a midsystolic click?
MVP
What happens to the murmur of mitral regurgitation during inspiration?
Nothing
What happens to the murmur of mitral regurgitation during isometric hand grip?
Increases (increased TPR “pushes” more blood back, increasing murmur)
What happens to the murmur of mitral regurgitation during squatting?
Increases (increased TPR “pushes” more blood back, increasing murmur)
What happens to the murmur of mitral regurgitation with administration of vasopressors?
Increases (increased TPR “pushes” more blood back, increasing murmur)
What happens to the murmur of mitral regurgitation with expiration?
Increases (all left sided murmurs increase with expiration)
Describe the murmur of MVP.
Midsystolic click with a late systolic crescendo murmur
What happens to the murmur of MVP with squatting?
Midsystolic click is later in systole and murmur is shorter and less intense (due to increased venous return causing increased preload)
What happens to the murmur of MVP with a Valsalva maneuver?
Makes midsystolic click earlier and lengthens murmur
What happens to the murmur of MVP with isometric hand grip?
Midsystolic click is earlier in systole and murmur is longer and more intense (increased TPR “pushes” more blood back and intensifies murmur)
What is Carvallo’s sign?
Tricuspid regurgitation murmur becoming louder during inspiration
What happens to the murmur of VSD during inspiration?
Nothing
What happens to the murmur of VSD with isometric hand grip?
Gets louder (increased TPR “pushes” more blood back and intensifies murmur)
What 3 murmurs are described as crescendo-decrescendo?
AS, PS, HOCM
What can be done to make a MR murmur worse?
Isometric handgrip, vasopressors, squatting (increase TPR), Expiration (increase left side return)
What can be done to make a MVP murmur worse?
Valsalva maneuver, standing (decrease venous return)
What position can you put the patient in to accentuate MS?
Left lateral decubitus
What murmur commonly radiates to the carotid arteries?
AS
Where does the murmur of AS commonly radiate?
Carotids
Describe an aortic stenosis murmur.
Systolic, crescendo-decrescendo murmur with an ejection click
What is pulsus parvus et tardus, and with what is it commonly seen?
Carotid pulse is weak with a delayed peak. Seen with aortic stenosis.
What are the three classic symptoms of aortic stenosis?
Syncope, angina, dyspnea (SAD)
What are the two most common etiologies of aortic stenosis?
Senile calcification of the valve, Bicuspid valve
What will happen to LV and aortic pressure (with respect to each other) on a pressure curve in a patient with aortic stenosis?
LV pressure will increase to a much greater extent than aortic pressure, creating a PRESSURE GRADIENT.
What is the #1 cause of mitral stenosis?
Rheumatic heart disease
Describe the murmur of HOCM.
Crescendo-decrescendo murmur resulting from ventricular septal hypertrophy
What will Valsalva maneuver do to the murmur of HOCM?
Make it louder
What will standing (from squatting) maneuver do to the murmur of HOCM?
Make it louder (decreased TPR)
What two murmurs are worsened by a Valsalva maneuver?
HOCM and MVP
What will amyl nitrite do to the murmur of HOCM?
Make it louder (decreased TPR allows more blood to be ejected through stenotic area)
What will isometric handgrip do to the murmur of HOCM?
Make it softer (increased TPR = less blood going through the stenotic “valve”)
What will squatting do to the murmur of HOCM?
Make it softer (increased TPR = less blood going through the stenotic “valve”)
What three things make the murmur of HOCM louder?
Valsalva, standing (from squatting), and amyl nitrate. Standing from squatting and amyl nitrate decrease TPR, allowing more blood to be forced through the stenotic area. Valsalva is kind of an oddball.
What two things make the murmur of HOCM softer?
Squatting and isometric handgrip (both increase TPR, thus reducing the amount of blood that is going through the stenotic “valve”)
What will amyl nitrite inhalation do to the murmur of AS?
Make it louder (decreased TPR = more blood able to go through stenotic valve)
What will isometric handgrip do to the murmur of aortic stenosis?
Make it softer (increased TPR = less blood able to go through stenotic valve)
What does inspiration do to the murmur of pulmonic stenosis?
Increases it
Describe the murmur of aortic regurgitation.
High pitched, early diastolic decrescendo “blowing” murmur.
Patient leaning forward during deep exhalation will accentuate with murmur?
Aortic regurgitation
What is an Austin-Flint murmur?
A rumbling murmur caused by aortic regurgitation where the regurgitant jet of blood closes the mitral valve, causing a functional mitral stenosis.
What is Duroziez sign and what is it associated with?
A systolic murmur over the femoral artery when the stethoscope is compressed proximally and a diastolic murmur over the femoral artery when it is compressed distally. Caused by aortic regurgitation.
What murmur causes a wide pulse pressure (difference between systolic and diastolic)?
Aortic regurgitation
What is Quincke’s pulse and what is it associated with?
Oscillation of blanching of nail beds after compression. Seen with aortic regurgitation.
What is a Corrigan pulse and what murmur causes it?
Palpable abrupt upstroke and rapid fall of arterial pulsation, caused by aortic regurgitation.
What is Traube sign and what murmur causes it?
Pistol shot sound over femoral artery, causd by aortic regurgitation.
What is Mueller sign and what murmur causes it?
Pulsating uvula caused by aortic regurgitation.
What is de Musset’s sign and what murmur causes it?
Head bobbing with each systole caused by aortic regurgitation.
What happens to the murmur of aortic regurgitation with administration of amyl nitrate?
Decreases (decreased TPR = not as much blood regurgitating backwards)
What happens to the murmur of aortic regurgitation during isometric hand grip?
Increases (increased TPR = more blood regurgitating backwards)
Patient’s head is bobbing with every heartbeat. What is this called and what murmur is it associated with?
de Musset’s sign, associated with aortic regurgitation.
What happens to the murmur of pulmonary stenosis with inspiration?
Gets louder
What murmur has an opening snap?
Mitral stenosis
Describe the murmur of mitral stenosis.
Delayed rumbling late diastolic murmur following an opening snap
What is indicative of worsening mitral stenosis?
Opening snap occurring CLOSER TO S2
A patient with MS has an opening snap that occurs closer to S2 than it used to. Explain.
The murmur is WORSENING
What happens to the murmur of tricuspid stenosis with inspiration?
Gets louder
Describe the murmur of PDA.
Continuous, MACHINE-LIKE murmur
What murmur is described as continuous and machine-like?
PDA
What is Beck’s triad?
Hypotension, JVD, and distant heart sounds (seen with pericardial tamponade)
A >10 mm Hg decline in systolic pressure during inspiration is called what? What is it associated with?
Exaggerated pulsus paradoxus, associated with pericardial tamponade (but not specific for it)
What is Kussmaul’s sign?
Increase in JVP during inspiration (normally, JVP decreases). Caused by constrictive pericarditis.
What are the symptoms of mitral stenosis?
Dyspnea (classic), right heart failure, hoarseness.
What two genetic disorders should you think about in a patient with MVP?
Ehlers-Danlos and Marfan syndromes
Aortic dilation can cause which murmur?
Mitral regurgitation (dilation pulls the valve open). Think syphilis!
