Heart Murmurs Flashcards
Aortic Stenosis
CRESCENDO- DECRESCENDO murmur R 2nd intercostal space
- increased murmur when leaning forward (ERBs) and increased venous return (squatting, supine, leg raise)
- pulsus parvus et tardus (weak, delayed carotid pulse)
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Etiology:
- degenerative: calcifications > 70 yo
- congenital & bicuspid valve <70 yo
-
S/sxs: ASH
- angina
- syncope
- heart failure
-
Dx:
- ECHO = best test
- ECG = L ventricular Hypertrophy
- Tx: aortic valve replacement = ONLY effective treatment
Aortic Regurgitation
Diastolic high-pitched blowing DECRESCENDO murmur along LSB +/- apex
- murmur LOUDER when sitting up and leaning forward
-
Etiology:
- acute → MI, aortic dissection, endocarditis
- chronic → aortic dilation, rheumatic fever, HTN
-
Physical Exam:
- Water hammer pulse: swift upstroked and rapid fall of radial pulse accentuated with wrist elevation
- De-Musset’s Sign: head-bobbing with heart beat
- Hill’s Sign: popliteal artery systolic pressure > brachial artery by 60 mmHg (most sensitive)
- Quincke’s Pulses: visible pulsations in the fingernail bed
- Muller’s Sign: visible systolic pulsations of the uvula
-
Dx:
- Echocardiogram → regurgitant jet
- L ventricular dilation as compensation
-
Tx:
- decrease the afterload improves the forward flow (e.g. ACE-I, ARBs, nifedipine, hydralazine)
- surgery = definitive tx
*
Mitral Stenosis
- Diastolic murmur heard best at the apex
-
LOUD S1 (forceful closure of mitral valve) with OPENING SNAP (forceful opening of mitral valve →early diastolic sound followed by a mid-diastolic rumbling murmur.
- → initial rumble during passive filling of ventricle, followed by active rapid filling during atrial “kick”
- Etiology: rheumatic heart disease = most common cause!
- S/sxs: increased L atrial pressure/volume overload → pulm congestion → pulm HTN → CHF
-
Dx:
- ECG = L atrial enlargement, A fib, pulmonary HTN (RVH, R axis deviation)
- ECHO = most useful non-invasive tool
- Cardiac Cath = most accurate but rarely done
-
Tx:
- percutaneous balloon valvuloplasty
Mitral Regurgitation
Systolic murmur Blowing Holosystolic murmur heard best at the APEX → murmur radiates to the axilla, can be heard well in the LLD position
-
Etiology: Mitral Valve prolapse = most common cause in the US
- rheumatic fever = most common in developing countries
- MI/ischemia → papillary muscle dysfunction
- dilated cardiomyopathy → ruptured chordae tendineae
-
S/sxs:
- dyspnea = most common, blood backs up into L atrium then lungs
-
Dx:
- ECHO = most useful non-invasive test
-
Tx: sx control by reducing afterload (ACE-I, ARBs)
- surgery = repair > replacement
Mitral Valve Prolapse
Mid-late systolic ejection click best heard at the apex
- → any maneuver that makes the LV smaller (decreases preload) results in an earlier click & longer murmur duration (e.g. valsalva, standing) due to increased prolapse
- MVP = MOST common cause of mitral regurgitation
-
Population:
- Most common in young women
-
Dx:
- ECHO → posterior bulging leaflets
-
Tx:
- MVP is associated with good prognosis → reassurance
- beta-blockers for pts with autonomic dysfunction
- mitral valve repair only for severe regurg and CHF
Pulmonary Stenosis
harsh mid-systolic crescendo-decrescendo murmur
- murmur increases with inspiration (bigger preload)
-
Pathophys:
- Right ventricle encounters more resistance → hypertrophy → less preload→ blood backs up
-
epidemiology:
- almost always congenital and in the young
- Tx: balloon valvuloplasty
Pulmonary Regurgitation
Diastolic decrescendo murmur best heart at the L upper sternal border
- murmur increases with inspiration and venous return
-
Pathophys:
- retrograde blood flow from the pulmonary artery into the Right Ventricle causing R-sided volume overload
-
Etiology:
- almost always congenital
Tricuspid Stenosis
mid-diastolic rumbling murmur at the lower left sternal border
- blood backs up into the R atrium causing R atrial enlargement which may lead to R-sided heart failure
-
Tx:
- decrease R atrial volume overload with diuretics and Na restriction
- surgery
Tricuspid Regurgitation
Holocystolic murmur at 4th ICS left midsternal border
- may radiate to liver
-
Pathophys:
- blood flows back into the R atrium
-
Etiology:
- functional overload (pulm HTN, RV dilation)
- dirty needles (staph etc often up on tricuspid valve)
-
PE:
-
Carvallo’s Sign:
- holosystolic murmur that becomes louder during inspiration
-
Carvallo’s Sign:
-
Tx:
- tx the underlying condition
- valve replacement
S3
Sys-tol-ic Murmur
can be normal in young and athletic hearts
associated with a dilated ventricle (more compliant ventricle)
S4
di-a-stol-ic
atrial kick against a stiff wall, associated with hypertrophy or scar
NEVER normal
What can accentuate mitral murmurs
Left lateral decubitus position with the bell
What can accentuate aortic murmurs
sitting up and leaning forward
What does increasing venous return do?
increases intensity of all murmurs EXCEPT hypertrophic cardiomyopathy, mitral valve prolapse
“the MVP Hates Conforming to the rules”
Pneumonic to remember which murmurs are diastolic
MS. PRARTS DIED
MS = mitral stenosis
PR = pulmonary regurg
AR = aortic regurg
TS = tricuspid stenosis
DIED = diastolic, everything else is a systolic murmur
