Mid-systolic click mid-to-late systolic murmur if MR present click and murmur occur earlier n systole with preload reduction (valsalva, standing) click and murmur occur late in systole with increased ventricular volume (squatting)

Heart Murmur Flashcards by Yoshiko Peterson

Normal Heart Sound

Consists of ____ & _____ sound

S1 & S2 or lab dab

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Normal Heart Sound

S1 caused by…

AV valves closure

*start of systolic ventricular contraction

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Normal Heart Sound

S2 sound is caused by…

semilunar valves closure

*once systolic contraction is complete

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Murmur

Features of Murmur:

SCRIPT

What are the characteristics?

Site: where is the murmur loudest?
Character: soft? blowing? crescendo? decrescendo? crescendo decrescendo?
Radiation: carotid (AS)? axilla (MR)?
Intensity: grade of murmur?
Pitch: high? low and grumbling? indicate velocity
Timing: systolic? dyastolic?

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Murmur

location associated with the heart sound

aortic area?

2nd right intercostal space

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Murmur

location associated with the heart sound

pulmonic area?

2nd left intercostal space

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Murmur

location associated with the heart sound

tricuspid area?

4th left intercostal space

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Murmur

location associated with the heart sound

mitral area?

5th left intercostal space (midclavicular)

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Murmur

murmurs are diagnosed based on:

Time they occur in the cardiac cycle: systolic or diastolic?
Shape: change in intensity over time
Location: auscultation site where they are best heard

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Systolic Murmurs

high pitched, blowing holosystolic (pansystolic) murmur that r_adiates to the_ axilla; it may be described as a blowing or high-pitched murmur
holosystolic - chronic
early systolic - acute
S3, S4 with heart failure
accentuated P2 with PH

*murmur starts at S1 when the AV valves are closed

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Systolic Murmurs

high pitched, holosystolic, blowing murmur that increases with inspiration
diastolic flow rumble
paradoxic splitting of S2

*loudest in the tricuspid area and the sound radiates up, along the left sternal border

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Systolic Murmurs

low pitched, harsh, systolic crescendo decrescendo murmur best heard at the right upper sternal border that may radiates up to the carotid artery

*often preceded by an ejection click caused by the opening of the stenotic valve

diastolic murmur if AR is present
S3, S4 with heart failure

*since the valve area is small, the blood flow starts small, rise to a maximum in mid-systole at the peak of ventricular contraction, then attenuates towards the end of systole

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Systolic Murmurs

Pulmonic stenosis

medium pitched, harsh, crescendo decrescendo systolic ejection murmur
heard at the left upper sternal border (pulmonic area); a thrill may also be present

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MVP murmur

Mid-systolic click
mid-to-late systolic murmur if MR present
click and murmur occur earlier n systole with preload reduction (valsalva, standing)
click and murmur occur late in systole with increased ventricular volume (squatting)

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What is murmur?

A cardiac murmur is caused by turbulent blood moving through the heart of great vessels. Murmurs are categorized by their location, timing, intensity, configuration, pitch and quality.

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Murmur

location

Murmur

timing

systolic, diastolic, continuous
systolic murmur: early, mid, late, holosystolic (pansystolic)
diastolic murmur: early, mid, late

Murmur

intensity *graded on a scale of I to VI

I: barely audible

II: faintly heard

III: moderately loud

IV: loud

V: very loud

VI: loud with a thrill ( can be heard with a stethoscope)

Murmur

Configuration

“A murmur is described by its change in intensity.”

Crescendo murmur – begins softly and becomes louder
Decrescendo murmur – begins loud and becomes softer
Crescendo-decrescendo murmur-begins softly, become louder, and then decreases in intensity
Decrescendo-crescendo murmur – begins loudly, becomes softer, then builds to the original intensity

Murmur

pitch

“The pitch of a murmur is determined by the blood flow velocity.”

High pitched murmur – best heard with the diaphragm

Low pitched murmur – best heard with the bell of the stethoscope

Medium pitched murmur – best heard with both diaphragm and bell of the stethscope

Murmur

quality

“A murmur’s quality may be described as blowing, rumbling, harsh, dull or rasping.”

Other Systolic Murmurs

Early systolic murmurs: begin with
the first heart sound and end in midsystole

what are the causes?

Small VSD
Large VSD with Pulmonary HTN
Severe acute or tricuspid regurgitation

Other Systolic Murmurs

Systolic ejection murmurs: begin after the semilunar valves open

What are the causes?

Valvular aortic or pulmonic stenosis
Dilatation of the aorta or pulmonary artery
Increased rate of ejection (heart block, fever, anemia, exercise,
thyrotoxicosis, and sometimes heard in normal individuals)

Pansystolic (holosystolic) murmurs: Present when there is
flow between two chambers that have widely different pressure
throughout systole, such as the left ventricle and the left atrium in MR

What are the causes?

MR or TR
VSDs
Aortopulmonary shunts

_Other Systolic Murmurs_ ## Footnote **Late systolic murmurs**: faint or moderately loud high-pitched apical murmurs start well after ejection and do not mask either normal heart sound What are the causes?

1. Papillary muscle dysfunction in patients with myocardial ischemia or infarction 2. Late systolic murmurs following midsystolic clicks are associated with late systolic MR caused by MVP

_Diastolic Murmurs_ AR

* **high-pitched**, **early**, **blowing,** **diastolic decrescendo** murmur at the _left sternal border_ * location: _aortic area_ * secondary systolic ejection murmur * S3, S4 with heart failure * **severe AR** murmur is a l**ow-pitched, mid-diastolic, rumble** at the _apex_ (**Austin Flint murmur**)

_Diastolic Murmurs_ PR

* high or **low-pitched**, **blowing decrescendo diastolic** murmur that may increase with respiration * **Loud P2** with PH * **Systolic ejection murmur** with **severe PR** due to increased flow * Location: **Erb’s point** \*_When_ **_PH_** _is present with PR_, a **high-pitched blowing diastolic** murmur may be heard (**Graham-Steele Murmur**)

_Diastolic Murmurs_ MS

* **low-pitched, diastolic, rumbling, crescendo-decrescendo** murmur with **opening snap** * loud **S1** * **holosystolic** murmur with **MR** * **accentuated P2** with **PH** * location: **mitral area**

_Diastolic Murmurs_ TS

* **high-pitched, diastolic rumble** with **respiration** and **opening snap** * Absence of normal respiratory splitting of S2 * Murmur of TR * Location: **Tricuspid area**

_Other Diastolic Murmur_ **Early diastolic murmurs**: begin immediately after the second heart sound What are the causes?

* AR * PR

_Other Diastolic Murmur_ Mid-diastolic and late diastolic murmurs: produced by the forward flow of blood through the atrioventricular valves What are the causes?

1. MS 2. TS 3. Left atrial myxoma (which may simulate a “stenotic” valve) 4. MR (increased flow) 5. Large left-to-right shunts (increased flow)

**continuous murmurs**: result from blood flow constantly moving from a high-pressure area to a low-pressure area What are the causes?

1. PDA 2. Systemic arteriovenous fistula 3. Coronary artery from the pulmonary artery 4. Communications between the sinus of Valsalva and the right side of the heart

Murmurs Response to Physiologic Maneuvers: **Valsalva Maneuvers**

Most murmurs decrease during the strain phase of the Valsalva maneuver except **hypertrophic obstructive cardiomyopathy** and **mitral valve prolapse**

Murmurs Response to Physiologic Maneuvers: **Isometric Handgrip**

**Sustained isometric handgrip** increases peripheral resistance, blood pressure, heart rate and cardiac output. _The handgrip_ **_increases_** _the left heart murmurs_ of **MR, AR, VSD**. The murmurs of **semilunar valve stenosis** and **hypertrophic cardiomyopathy** will be **reduced** with sustained isometric handgrip.

_Cardiac Maneuvers_ Inspiration…

accentuates right-side heart murmur such as TR and TS \*inspiration = increase preload to right heart due to decrease in thoracic pressure \*If heart sound is louder during inspiration = right-sided lesion i.e. TR/TS/PR/PS, myxoma in the RV \*key word: increase with inspiration

_Cardiac Maneuvers_ Valsalva

* increases abdominal pressure = compress veins = reduce the blood flow returning to the heart * reduced preload

_Cardiac Maneuvers_ Squatting

* easier for the blood in the vein in your legs to return to the heart * increase preload

Murmurs Response to Physiologic Maneuvers: **Amyl Nitrite**

**Amyl nitrite** is a _fast acting vasodilator_. The inhalation of amyl nitrite will initially **decrease venous return and blood pressure**. It will augment **left ventricular outflow tract obstruction murmurs** such as **hypertrophic obstructive cardiomyopathy**. **MVP** _may be enhance with amyl nitrite_ _inhalation_. **Amyl nitrite** will **decrease** the murmurs of **AR, MR**, and **VSD**. The forward flow murmurs such as **MS** _increase with the administration of_ **_amyl nitrite_**.