Heart Murmurs Flashcards
What are the causes of aortic stenosis?
Senile calcification
Bicuspid aortic valve
Rheumatic heart disease
What is the presentation of aortic stenosis?
Usually asymptomatic
When symptomatic, start to worry. Symptoms are: chest pain, SOB, syncope. This is due to decreased CO.
What are the signs of aortic stenosis?
Slow rising pulse Narrow pulse pressure Crescendo-decrescendo Ejection SYSTOLIC murmur High pitched
Most commonly heard in the second intercostal space
What is the management of aortic stenosis?
If asymptomatic, observe the patient
If symptomatic and stable: valve replacement
If symptomatic and unstable: balloon valvuloplasty
What medication is contra-indicated in aortic stenosis?
Nitrates
What are the signs of aortic regurgitation?
Diastolic murmur (heard best in expiration when patient is sat forward) Collapsing pulse (Water-hammer or Corrigan's or de Musset's pulse) Wide pulse pressure
In severe AR, Austin-Flint murmur will be heard (regurgitation hits against the mitral valve causing a mitral stenosis)
What are the causes of aortic regurgitation?
Due to valve dysfunction: rheumatic fever, bicuspid aortic valve, infective endocarditis
Due to aortic root disease: Marfan’s, Ehlers-Danlos, hypertension, aortic dissection
What are the complications of aortic stenosis, mitral stenosis, aortic regurgitation and mitral regurgitation?
Aortic and mitral stenosis: left ventricular/left atrial hypertrophy
Aortic and mitral regurgitation: left ventricular dilatation/left atrial dilatation
What is the management of aortic regurgitation?
Reduce systolic hypertension
ACE-i. Echo every 6-12 months.
What are the causes of mitral stenosis?
RHEUMATIC FEVER
What is mitral stenosis?
What is the presentation of mitral stenosis?
Narrowing of mitral valve, so there is a struggle to push blood through to the left ventricle.
SOB, haemoptysis
Hoarseness (pressure on recurrent laryngeal nerve)
Dysphagia (oesophagus)
Bronchial obstruction
What are the signs of mitral stenosis?
Diastolic murmur (best heard in expiration while patient is lying on left)
Loud S1, opening snap
Malar flush on cheeks
AF (due to enlarged left atrium)
What do tests show in mitral stenosis?
Possible AF
On CXR, left atrial enlargement (double shadow in right cardiac silhouette)
Pulmonary oedema
Echo is diagnostic
What are the indications for cardiac catheterization for mitral stenosis?
Previous valvotomy
Angina
Severe pulmonary hypertension
Calcified mitral valve
What is the management of mitral stenosis?
If in AF: RATE CONTROL and anticoagulate with warfarin.
If this fails to control symptoms, balloon valvuloplasty.
What makes a mitral stenosis murmur louder?
After a Valsalva manouvre
After exercise
Squatting/hand gripping
What is the main complication of mitral regurgitation?
Congestive heart failure
What are the two most common heart murmurs?
1) Aortic stenosis
2) Mitral regurgitation
What are the signs of mitral regurgitation?
Pansystolic murmur ‘blowing’. Best heard at the apex and it radiates to the axilla.
Soft S1 and split S2 may occur.
What may tests show in mitral regurgitation?
Broad P wave (atrial enlargement)
Cardiomegaly may be seen
What is the management of mitral regurgitation?
Increase CO: nitrates, diuretics, positive inotropes, intra-aortic balloon pump
If in heart failure, ACE inhibitors may be considered alongside beta blockers and spironolactone
How does a mitral valve prolapse present?
Inferior T wave inversion
Mid systolic click/late systolic murmur
Atypical chest pain, palpitations, autonomic dysfunction symptoms.
In an examination, how do you assess a murmur properly?
Use 'SCRIPT' Site: where is it loudest? Character: soft/blowing/crescendo/decrescendo Radiation Intensity: what grade is the murmur? Pitch: high/low/grumbling Timing: systolic or diastolic
What is the grading of murmurs?
Use the Levine scale
1) Difficult to hear
2) Quiet
3) Easy to hear
4) Easy to hear with a palpable thrill
5) Can hear with a stethoscope barely touching the chest
6) Can hear with a stethoscope off the chest
What does a third heart sound present as?
Normal in younger patients, pregnancy and in athletes
Sounds like ‘Ken-tucky’. There is a gap after S2.
May signify heart failure, cardiomyopathy, or severe regurgitation.
Should only be heard with a bell.
Which patients are at increased risk of developing infective endocarditis?
Acquired valvular disease Valve replacement Structural congenital heart disease Previous infective endocarditis Hypertrophic cardiomyopathy
