CARDIO: Murmurs

Question 1

Which murmurs increase with squatting?

Answer 1

Most valvular murmurs

Question 2

Which murmurs decrease with squatting?

Answer 2

Mitral valve prolapse and HCM

Question 3

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?

Answer 3

Mitral Valve Prolapse
HCM
Aortic Stenosis (hand grip)

Question 4

An intense holosystolic murmur best heard at the cardiac apex is consistent with___________

Answer 4

severe mitral regurgitation

Question 5

In severe MR, we expect to also find what on auscultation that helps us exlude MR as an etiology of a murmur.

Answer 5

S3 gallop is commonly heard in pts w/severe MR. It can also be heard in decompensated heart failure.

Question 6

An opening snap is often heard in pt’s w/ ___________________

Answer 6

mitral stenosis

Question 7

A late-peaking crescendo-descescendo systolic murmur heard best at the RUsternal border and has delayed pulses (pulsus parvus et tardus)

Answer 7

Aortic Stenosis

Question 8

Where do you listen for the pulmonary valve?

Answer 8

2. Pulmonary area: 2nd left parasternal ICS
   - Ideal site for auscultation of pulmonary valve murmurs
3. 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).
4. Pulmonary area: 2nd left parasternal ICS
   - Ideal site for auscultation of pulmonary valve murmurs
5. Tricuspid area: 4th left parasternal ICS
   - Ideal site for auscultation of tricuspid valve murmurs
6. 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).

Question 9

S1 heart sound occurs with the closing of the

Answer 9

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.

Question 10

S1 coincides with what part of the ECG?

Answer 10

QRS complex

Question 11

S2 coincides with what part of the ECG?

Answer 11

Completion of ventricular repolarization so at the end of the T wave

Question 12

What is physiologic splitting?

Answer 12

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.

Question 13

S2 split during _______________ is likely pathologic

Answer 13

EXPIRATION

Question 14

Wide splitting S2 indicates that there is a _____________________, this can often be due to _____________________, _________________________, or _____________________

Answer 14

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

Question 15

Fixed split S2 is indicative of

Answer 15

Atrial Septal Defect

Degree of splitting is independent of inspiration/expiration

Question 16

Paradoxical S2 splitting can be due to…

Answer 16

Aortic stenosis, LBBB

Question 17

What leads to an S3 gallop?

Answer 17

High output states, pregnant women, athletes, volume overload (like with aoritic vlave regurg or dialated cardiomyopathy)

Question 18

Kentucky

Answer 18

s3

Question 19

Tennessee

Answer 19

s4

Question 20

What can generate an S4?

Answer 20

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

Question 21

pulmonary arterial hypertension, right bundle-branch block, or pulmonary stenosis may lead to what on auscultation?

Answer 21

Wide splitting of S2 from delayed closing of pulmonic valve

Question 22

Which additional heart sound can be normal in pregnant women?

Answer 22

S3

The S3 gallop can be normal in pregnant women, athletes, and children.

Question 23

Standing and valsalva _____________________ venous return to the heart

Answer 23

decrease

Question 24

Murmur that is systolic, vibratory, best heard over LLSB, and increases in intensity when supine auscultated in a child is consistent with a _____________ murmur

Answer 24

Still Murmur

(An ‘Innocent murmur’)

Question 25

systolic ejection murmur best heard over LUSB and may radiate to axilla

Answer 25

Pulmonic flow murmur

(an innocent murmur)

Question 26

Best heard over the supra or infraclavicular area with decreased intensity with neck rotation

Answer 26

venous hum

(an innocent murmur)

Question 27

Systolic murmurs heard in the Aortic area

Answer 27

Aortic stenosis
Flow murmur
Aortic Valve Sclerosis

Question 28

Systolic Ejection murmur heard in pulmonic area

Answer 28

Pulmonic stenosis
ASD
Flow murmur

Question 29

Murmurs heard in the Tricuspid area

Answer 29

Holosystolic murmurs including tricuspid regurg or VSD
Diastolic murmurs including tricuspid stenosis

Question 30

Mumurs heard at apex/mitral area

Answer 30

systolic:
mitral regurg
mitral prolapse

Diastolic:
mitral stenosis

Question 31

Which murmurs increase with inspiration?

Answer 31

Right sided murmurs

Question 32

Pulsus parvus et tardis will be seen with________

Answer 32

Aortic stenosis

Question 33

Usually benign, can predispose pt to infective endocarditis. Can be caused by rhematic fever, chordae rupture, or myxamatous degenderation or connective tissue disease

Answer 33

Mitral valve prolapse

Question 34

What am I?

Answer 34

Question 35

What am I?

Answer 35

AV regurg or VSD

Question 36

Late and highly specific sequelae of rheumatic fever

Answer 36

Mitral stenosis

Question 37

Myxomatous degeneration leading to valve weakening is seen in the _________ valve leading to _______________

Answer 37

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.

Question 38

What diastolic murmurs should you be aware of?

Answer 38

Mitral stenosis, aortic regurg

Question 39

Dx:
-Echo shows increase LA size with normal LV
-Ausc shows mis diastolic murmur with rumble at cardiac apex
-opening snap

Answer 39

Mitral stenosis

Question 40

Which chamber would you expect to be dialated in mitral stenosis and why?

Answer 40

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

Question 41

How does mitral annular calcification differ from rheumatic calcification?

Answer 41

Annular calcification is often seen in pts over 65 and rarely causes hemodynamically significant mitral valve dysfunction

Question 42

Why might a pt with OSA show signs of increased right sided heart pressures?

Answer 42

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.