Ch16: Heart Sounds and Murmurs Flashcards
clinical presentation of ACS in someone 75yo or older
- dyspnea
- neuro symptoms (syncope, weakness, acute confusion)
- chest pain or pressure in <50% of cases
- unusual fatigue in weeks leading up to event
_____ should be considered with any acute illness in the elder
ACS (get ECG)
most valvular disease is found in the _____ side of the heart
left (aortic and mitral)
which side of the heart is a higher pressure system
left sided (arterial)
what is the PMI
palpable sensation of the underlying left ventricle
normally at 5th intercostal space, mid-clavicular line
displaced PMI usually indicates….
increased LV volume
when PMI is displaced, it usually moves…..
laterally, towards mid-axillary line
unusually forceful, sustained PMI indicates….
pressure overload, poorly-controlled HTN
best patient position for palpating PMI
left lateral decubitus (side lying) position
(3) reasons the PMI may be difficult to palpate
- COPD (increase in AP diameter of thorax)
- obesity
- thick chest wall (e.g., body builder)
heart sound heard best at the 2nd intercostal space, right sternal border
aortic valve
murmur will often radiate to the neck
heart sound at the 2nd intercostal space, left sternal border
pulmonic valve
heart sound at the 5th intercostal space, mid-clavicular line
mitral valve
murmur will often radiate to the axilla
significance of S1
marks the beginning of SYSTOLE
produced by closure of the mitral and tricuspid valves (atrioventricular valves)
where/how is S1 heard best
apex of the heart (bottom; closer to pt feet)
listen with the diaphragm of stethoscope
significance of S2
end of systole
closure of the aortic and pulmonic valves (semilunar valves)
where/how is S2 heard best
base of the heart (top, towards the head)
with the diaphragm
significance of physiologic split S2
physiologic
widening of the normal interval between aortic and pulmonic components of the second heart sound (delay in the pulmonic component)
benign finding particularly <30yo
where/how is a physiologic split S2 heard best
pulmonic region (2nd ICS, left sternal border – this is because is due to a delay in the pulmonic valves after closure of the aortic valve)
increases during inspiration
for whom is it common to have a physiologic split S2
majority of adults <30yo, benign finding
how to differentiate a physiologic vs. pathologic split S2
PHYSIOLOGIC = INcreases with INspiration
PATHOLOGIC = fixed (no change with inspiration), or paradoxical split (narrows or closes with inspiration)
where is a pathologic split S2 heard
(same place) pulmonic region (2nd ICS, left sternal border
significance of a pathologic split S2 …
- uncorrected atrial-septal defect (congenital heart defect; only congenital heart defect more commonly found in females > males) - USUALLY FIXED SPLIT
- LBBB and other conditions that delay aortic valve closure - USUALLY PARADOXICAL SPLIT
significance of pathologic S3 heart sound
marker of ventricular overload and/or systolic dysfunction
most often occurs in heart failure (alongside dyspnea, tachycardia, crackles)
when/where is S3 heard best
- heard in early diastole
- low pitched, best heard with the bell (might miss with diaphragm)
- can sound like it is “hooked on” to the back of S2
- can resolve with treatment of underlying condition
significance of S4 heart sound
marker of poorly controlled HTN
most commonly found in someone with:
- uncontrolled HTN
- recurrent myocardial ischemia
when/where is S4 heard best
- heard late in diastole
- can sound like it is “hooked on” to the front of S1, “pre-systolic”
- soft, lower-pitched
- best heard with bell of the stethoscope
S3 and S4 are best heard with diaphragm or bell?
bell
stenosis or incompetence: failure of a valve to CLOSE adequately
incompetent
stenosis or incompetence: failure of a valve to OPEN adequately
stenosis
[stenotic vs. incompetent] valves cause regurgitant murmurs
incompetent
[systolic vs. diastolic] heart murmurs are ALWAYS pathologic
diastolic
MR. PASS - MVP mnemonic for systolic murmurs
Mitral Regurgitation Physiologic (innocent) Aortic Stenosis Systolic
Mitral
Valve
Prolapse
mitral regurgitation murmur:
A. holosystolic?
B. crescendo-decrescendo?
holosystolic murmur
aortic stenosis murmur:
A. holosystolic?
B. crescendo-decrescendo?
crescendo-decrescendo systolic murmur
(3) systolic murmurs
- mitral regurgitation
- aortic stenosis
- mitral valve prolapse
mid-systolic click with late systolic murmur
mitral valve prolapse
MS. ARD diastolic murmurs
Mitral Stenosis Aortic Regurgitation Diastolic
early diastolic murmur
aortic regurgitation
late diastolic murmur
mitral stenosis
Grade 1/6 heart murmur
very faint, really need to “tune in” (usually not heard by the PCP unless very thin chest wall, good hearing, and quiet environment - aka not very common to find in primary care)
Grade 2/6 heart murmur
quiet but immediately heard
Grade 3/6 heart murmur
moderately loud, but without thrill (about as loud as S1 or S2)
Grade 4/6 heart murmur
loud with a thrill (tremor or vibration on palpation)
Grade 5/6 heart murmur
very loud with thrill
Grade 6/6 heart murmur
audible even without stethoscope
tremor or vibration on palpation over the chest wall
thrill
(4) descriptive characteristics of murmurs
harsh, rumble, blowing, musical
rumbling murmur, “bowling ball down a gutter”, diastolic
mitral stenosis
harsh, heard with both bell and diaphragm, crescendo-decrescendo systolic
aortic stenosis
blowing, high-pitched, early diastolic murmur
aortic regurgitation
a systolic murmur is likely benign if all of the following are true……
- negative cardiac history (e.g., no chest pain, dyspnea, syncope)
- grade 3 or less
- no radiation beyond the precordium (e.g., doesn’t radiate to axilla or carotids)
- S1 and S2 are intact
- no heave or thrill with palpation
- PMI in normal place
- murmur softens or disappears with supine to standing position change
most likely to hear a murmur when a patient is in what position
supine (more blood flow in the heart)
next step in evaluating a heart murmur that is suspected pathologic
echocardiogram
a systolic murmur is likely pathologic if even just one of these is true…..
- abnormal cardiac history (e.g., chest pain, dyspnea)
- higher grade 4 or above
- radiates beyond the precordium to the neck or axilla
- S1 and S2 obliterated
- thrill or heave on palpation
- PMI displacement
- murmur increases in intensity with supine to stand position change
18yo M presents for sports physical. asymptomatic. no significant PMH.
2/6 harsh systolic murmur, radiates to the neck, softer towards the axilla
heard best over the 2nd intercostal space, right sternal border
somewhat softer with supine to standing position change
you suspect…..
aortic stenosis
(congenital if develops in someone this young)
key determining from physiologic here was radiating to the neck
82yo F
CC: “i get really dizzy when i walk up a flight of stairs”
no chest pain. +DOE, resolves with rest
BP 110/90
Grade 2/6 harsh systolic murmur with radiation to the neck, loudest along upper sternal border, softer towards axilla. No S3 or S4. No carotid bruit or neck vein distention. +delayed carotid upstroke
you suspect….
aortic stenosis s/t calcific aortic stenosis
narrow pulse pressure tells you that she is having trouble getting blood out of her heart, not enough systolic pressure
delayed carotid upstroke tells you having trouble getting blood out of the left ventricle
when should the carotid upstroke be felt in relation to S1/S2, normally
nearly simultaneously with S1
most common cause of aortic stenosis in older adults
calcific aortic stenosis
so calcified that it doesn’t open well - can often not close well, too, so may have aortic regurgitation (incompetence) as well
how to differentiate carotid bruit vs. radiating murmur
CAROTID BRUIT = usually in the context of high grade atherosclerotic disease in the carotids
- softer
- usually unilateral
- different sound than that heard in the chest, different tone
RADIATING MURMUR
- same sound and timing as that found in the chest
- usually bilateral
- usually louder
62yo M
PMH: HTN, CHF
asymptomatic
physical exam:
PMI at 5th intercostal space anterior axillary line, sustained impulse
grade 3/6 blowing holosystolic murmur with radiation to the axilla. accentuated by rolling onto left side. softens when going from supine to standing, louder with hand grip. S2 is not preserved. carotid upstroke bilaterally is noted
you suspect….
mitral regurgitation s/t LVH
hypertensive heart disease and heart failure = LVH. LVH shifts the PMI laterally, and also pulls apart the mitral valve causing regurgitation on closure
27yo F presents for pap test. no significant PMH. physically active runs 5-7 miles 5x per week
meds: OCPs, MVI
physical exam: BMI 22 mild pectus excavatum (funnel chest) PMI WNL Normal S1/S2 mid-systolic click with late systolic murmur. Murmur moves forward (increases in length) with position change from supine to standing
you suspect….
mitral valve prolapse
obtain an echocardiogram as a next step
S1 should be louder than S2 at the….
apex
S2 should be louder than S1 at the….
base
most common cause of sudden cardiac death in young athletes
hypertrophic cardiomyopathy (33% of all sudden cardiac deaths; second leading cause was blunt trauma [cardiac concussion])
(5) major symptoms to ask about heart disease
- chest pain
- HF symptoms (e.g., orthopnea, edema)
- palpitations
- syncope
- activity intolerance/DOE
do you need antibiotic prophylaxis for any benign/physiologic heart murmurs?
no
% of thin, healthy adults with a physiologic heart murmur
~80%
Grade 1-4/6 harsh systolic murmur, usually crescendo-decrescendo pattern, heard best at the 2nd Right ICS, apex, softens with standing. Radiates to the carotids
aortic stenosis
most common cause of aortic stenosis in young, healthy adults
congenital bicuspid aortic valve
most common (2) causes of aortic stenosis in older adults
- calcific
- rheumatic
grade 1-3/4 high pitched, blowing, diastolic murmur heard best at the 3rd Left ICS, enhanced with forced expiration and leaning forward
aortic regurgitation
most common (2) causes of aortic regurgitation
- rheumatic heart disease, most commonly
- tertiary syphilis (rarely)
more common in males
grade 1-3/4, low-pitched, late diastolic murmur heard best at the apex, no radiation. Short crescendo-decrescendo rumble like a bowling ball rolling down an alley or distance thunder. enhanced in the left lateral decubitus position and with squatting and coughing
mitral stenosis
most common cause of mitral stenosis
rheumatic heart disease
grade 1-3/6 systolic ejection murmur at the pulmonic area with a widely spit S2
atrial-septal defect
grade 1-4/6 high pitched, blowing, holosystolic murmur often extending beyond S2. often radiates to the axilla, decreases with standing or valsalva, increases with squat or hand-grip
mitral regurgitation
grade 1-3/6 late systolic crescendo murmur with honking quality heart best at the apex. murmur is preceded by a midsystolic click
mitral valve prolapse
general principles regarding infective endocarditis prophylactic antibiotics
- infectious endocarditis is far more likely to result from frequent exposure to random bacterias in daily life than it is to be caused by a dental, GI, or GU procedure
- prophylactic abx likely prevents only an exceedingly small number of cases
- the risk of antibiotic-associated AEs exceeds the benefit
- maintenance of optimal oral health and hygiene reduces the risk of infective endocarditis more than prophylactic abx does
cardiac conditions associated with the highest risk of adverse outcomes from infective endocarditis for which prophylaxis with dental procedures MAY be reasonable…. (4)
- prosthetic cardiac valve
- previous infective endocarditis
- congenital heart disease
- cardiac transplant recipients who develop cardiac valve disease
first line antibiotic regimen for infective endocarditis prophylaxis
amoxicillin 2g PO 30-60 minutes before procedure
