CARDIO: Murmurs Flashcards
Which murmurs increase with squatting?
Most valvular murmurs
Which murmurs decrease with squatting?
Mitral valve prolapse and HCM
There are very few murmurs that become less prominent when ventricular blood volume is increased with passive leg raise/squatting/handgrip. Which ones come to mind?
Mitral Valve Prolapse
HCM
Aortic Stenosis (hand grip)
An intense holosystolic murmur best heard at the cardiac apex is consistent with___________
severe mitral regurgitation
In severe MR, we expect to also find what on auscultation that helps us exlude MR as an etiology of a murmur.
S3 gallop is commonly heard in pts w/severe MR. It can also be heard in decompensated heart failure.
An opening snap is often heard in pt’s w/ ___________________
mitral stenosis
A late-peaking crescendo-descescendo systolic murmur heard best at the RUsternal border and has delayed pulses (pulsus parvus et tardus)
Aortic Stenosis
Where do you listen for the pulmonary valve?
- Pulmonary area: 2nd left parasternal ICS
- Ideal site for auscultation of pulmonary valve murmurs - Aortic area: 2nd right parasternal intercostal space (ICS)
- Ideal site for auscultation of aortic valve murmurs (1a). The murmur of aortic stenosis also radiates to the carotid arteries (1b). - Pulmonary area: 2nd left parasternal ICS
- Ideal site for auscultation of pulmonary valve murmurs - Tricuspid area: 4th left parasternal ICS
- Ideal site for auscultation of tricuspid valve murmurs - Mitral area: 5th left ICS in the midclavicular line (over the cardiac apex)
- Ideal site for auscultation of mitral valve murmurs (4a). The murmur of mitral regurgitation also radiates to the left axilla (4b).
S1 heart sound occurs with the closing of the
tricuspid and mitral valves
at the start of systole*
They open during diastole so that the relaxing ventricles can fill with blood from the atria. When the ventricles contract during systole, the pressure in the ventricles rapidly increases. The increase in pressure pushes the atrioventricular valves closed, resulting in the first heart sound, or “lub.” The S1 sound is caused by the closure of the valves.
S1 coincides with what part of the ECG?
QRS complex
S2 coincides with what part of the ECG?
Completion of ventricular repolarization so at the end of the T wave
What is physiologic splitting?
The S2 sound is normally heard as the closure of the aortic and pulmonary valves in close succession. We refer to these as A2 and P2, for the closure of the aortic valve and pulmonary valve, respectively.
S2 is split during INSPIRATION. Normally, the S2 sound should not be split during expiration.
S2 split during _______________ is likely pathologic
EXPIRATION
Wide splitting S2 indicates that there is a _____________________, this can often be due to _____________________, _________________________, or _____________________
Any condition that causes delayed closure of the pulmonary valve will cause a wide splitting s2
often due to:
PAH, RBBB, PulmStenosis
PAH–> ILD or PE
Pulmonic area: 2nd left parasternal intercostal space
Fixed split S2 is indicative of
Atrial Septal Defect
Degree of splitting is independent of inspiration/expiration
Paradoxical S2 splitting can be due to…
Aortic stenosis, LBBB
What leads to an S3 gallop?
High output states, pregnant women, athletes, volume overload (like with aoritic vlave regurg or dialated cardiomyopathy)
Kentucky
s3
Tennessee
s4
What can generate an S4?
When the walls of the ventricle are stiff and noncompliant (concentric ventricular hypertrophy), as they are after longstanding hypertension, HCM, aortic stenosis, they are less able to flex or bend. During the atrial systole phase of the cardiac cycle, the blood that is actively pushed into the ventricles hits against these stiff ventricular walls and causes the blood in the ventricles to reverberate (atrial kick). When this occurs in a stiff heart, the stiff walls recoil against the atrial kick and produce the S4 sound.
An S4 is heard immediately before S1, initiating a cadence that resembles that of the word “Ten-nes-see,” with the syllables corresponding to the heart sounds S4-S1-S2.
This is considered an s4 gallop
pulmonary arterial hypertension, right bundle-branch block, or pulmonary stenosis may lead to what on auscultation?
Wide splitting of S2 from delayed closing of pulmonic valve
Which additional heart sound can be normal in pregnant women?
S3
The S3 gallop can be normal in pregnant women, athletes, and children.
Standing and valsalva _____________________ venous return to the heart
decrease
Murmur that is systolic, vibratory, best heard over LLSB, and increases in intensity when supine auscultated in a child is consistent with a _____________ murmur
Still Murmur
(An ‘Innocent murmur’)
systolic ejection murmur best heard over LUSB and may radiate to axilla
Pulmonic flow murmur
(an innocent murmur)
Best heard over the supra or infraclavicular area with decreased intensity with neck rotation
venous hum
(an innocent murmur)
Systolic murmurs heard in the Aortic area
Aortic stenosis
Flow murmur
Aortic Valve Sclerosis
Systolic Ejection murmur heard in pulmonic area
Pulmonic stenosis
ASD
Flow murmur
Murmurs heard in the Tricuspid area
Holosystolic murmurs including tricuspid regurg or VSD
Diastolic murmurs including tricuspid stenosis
Mumurs heard at apex/mitral area
systolic:
mitral regurg
mitral prolapse
Diastolic:
mitral stenosis
Which murmurs increase with inspiration?
Right sided murmurs
Pulsus parvus et tardis will be seen with________
Aortic stenosis
Usually benign, can predispose pt to infective endocarditis. Can be caused by rhematic fever, chordae rupture, or myxamatous degenderation or connective tissue disease
Mitral valve prolapse
What am I?
What am I?
AV regurg or VSD
Late and highly specific sequelae of rheumatic fever
Mitral stenosis
Myxomatous degeneration leading to valve weakening is seen in the _________ valve leading to _______________
Mitral, mitral valve prolapse
Myxomatous degeneration (A pathologic increase in the deposition of glycosaminoglycans in tissue) of the mitral valve can weaken the valve and result in mitral valve prolapse. Can be due to a connective tissue disorder.
What diastolic murmurs should you be aware of?
Mitral stenosis, aortic regurg
Dx:
-Echo shows increase LA size with normal LV
-Ausc shows mis diastolic murmur with rumble at cardiac apex
-opening snap
Mitral stenosis
Which chamber would you expect to be dialated in mitral stenosis and why?
Left Atria, LV would be normal
Mitral stenosis impairs diastolic filling of the left ventricle and causes and increase in left atrial pressure, can lead to increase stretching of left atrial walls and increase risk of afib
How does mitral annular calcification differ from rheumatic calcification?
Annular calcification is often seen in pts over 65 and rarely causes hemodynamically significant mitral valve dysfunction
Why might a pt with OSA show signs of increased right sided heart pressures?
Chronic untreated OSA can result in pulm htn which can manifest w/ heart murmurs or loud pulmonic heart sounds and eventually right sided heart failure.
