Heart murmurs

Question 1

What is the murmur character of aortic stenosis?

Answer 1

Ejection systolic

Question 2

Where is aortic stenosis best heard and where does it radiate to?

Answer 2

Upper right sternal edge Radiates to carotid and apex

Question 3

What is the pathology of aortic stenosis?

Answer 3

Increased resistance between left ventricle and systemic circulation –> limited CO –> LV hypertrophy

Question 4

What are the symptoms of aortic stenosis?

Answer 4

Dyspnoea
Syncope
Angina (coronary perfusion impaired) §

Question 5

What are the signs of aortic stenosis?

Answer 5

1. Slow rising pulse
2. Narrow pulse pressure
3. Heaving apex beat (pressure loaded)
4. Soft or absent S2 (depending on AS severity)
5. May be signs of LVF (S3, pulmonary oedema )

Question 6

What are the causes of aortic stenosis? (use the pneumonic)

Answer 6

ABCs
A - Age (senile calcification - most common cause)
B - Bicuspid aortic valve (Turner’s syndrome)
C - Congenital
Strep-associated (rheumatic heart disease)

Question 7

What is the murmur character in Aortic sclerosis?

Answer 7

Ejection systolic

Question 8

Where is aortic sclerosis best heard and where does it radiate to?

Answer 8

Upper right sternal edge (does not radiate)

Question 9

What is the pathology of aortic sclerosis?

Answer 9

Valve hard and inflexible (thickened NOT narrowed) –> Turbulence –> local sound only

Question 10

What are the symptoms of aortic sclerosis?

Answer 10

None!

Question 11

What are the signs of aortic sclerosis?

Answer 11

No abnormal signs - this is how you differentiate from aortic stenosis (normal pulse pressure, normal apex beat, and S2)

Question 12

What are the causes of aortic sclerosis?

Answer 12

Senile calcification

Question 13

What is the murmur character in Mitral regurgitation?

Answer 13

Pansystolic

Question 14

Where is mitral regurgitation best heard and where does it radiate to?

Answer 14

Apex

radiates into the left axilla

Question 15

What is the pathology of mitral regurgitation?

Answer 15

Backflow of blood from the left ventricle into left atrium during systole –> LV and left atrial dilation –> Pulmonary HTN

Question 16

What are the symptoms of mitral regurgitation?

Answer 16

Dyspnoea 
Orthopnoea 
Paroxysmal nocturnal dyspnoea
Fatigue 
Palpitations

Question 17

What are the signs of mitral regurgitation?

Answer 17

Atrial fibirillation
Displaced thrusting apex (volume -loaded)
Soft S1
Signs of pulmonary HTN (RV heave, loud P2)
May be signs of LVF (S3, pulmonary oedema)

Question 18

What are the causes of mitral regurgitation ?

Answer 18

Papillary muscle dysfunction 
(post MI) 
Dilated cardiomyopathy 
Rheumatic heart disease 
Infective endocarditis 
Congenital 
Connective tissue disease (e.g. Marfan's)

Question 19

What is the murmur character in mitral valve prolapse?

Answer 19

Mid-systolic click and/or late systolic murmur

differentiate from mitral regurgitation by normal S1 then gap before the murmur (hence a late systolic)

Question 20

Where is mitral valve prolapse best heard and where does it radiate to? Is it louder on inspiration or expiration?

Answer 20

Heard loudest in the apex - radiates to the left axilla and back

Question 21

What is the pathology of mitral valve prolapse?

Answer 21

In ventricular systole, a mitral valve leaflet prolapses int the left atrium

Question 22

What are the symptoms of mitral valve prolapse?

Answer 22

Atypical chest pain

Question 23

What are the signs of mitral valve prolapse?

Answer 23

Murmur only (can develop significant MR)

Question 24

What are the causes of mitral valve prolapse?

Answer 24

Associated with: Marfan’s, PKD, Congenital heart disease, HCM, SLE, muscular dystrophy

Question 25

What is the murmur character in ventricular septal defect?

Answer 25

Pansystolic, loud and machinery-like murmur

Question 26

Where is ventricular septal defect best heard and where does it radiate to?

Answer 26

Lower left sternal edge | loud- radiates to the whole praecordium

Question 27

What is the pathology of ventricular septal defect?

Answer 27

During systole, blood from the LV leaks into the RV

Question 28

What are the symptoms of ventricular septal defect?

Answer 28

Often none if small

Question 29

What are the signs of ventricular septal defect?

Answer 29

Signs of pulmonary HTN (RV heave, loud P2) | If acute may cause cardiogenic shock

Question 30

What are the causes of ventricular septal defect?

Answer 30

Congenital | Complication of acute MI

Question 31

What is the murmur character in tricuspid regurgitation?

Answer 31

Pansystolic (differentiate from mitral regurgitation by seeing if it is louder on inspiration)

Question 32

Where is tricuspid regurgitation best heard and where does it radiate to?

Answer 32

Lower left sternal edge

Question 33

What is the pathology of tricuspid regurgitation?

Answer 33

Blood flowing from the RV to the right atrium during systole --> increased right atrial and venous pressures

Question 34

What are the symptoms of tricuspid regurgitation?

Answer 34

Fatigue Hepatic pain on exertion Ascites Peripheral oedema

Question 35

What are the signs of tricuspid regurgitation?

Answer 35

Giant V waves in JVP Backflow signs (peripheral oedema, ascites, pulsatile hepatomegaly) Signs of lung disease and pulmonary HTN (RV heave, loud P2) - if that is the cause

Question 36

What are the causes of tricuspid regurgitation?

Answer 36

Most commonly due to RV dilation in pulmonary HTN (e.g. in chronic lung disease or left heart/valve disease) Rheumatic heart disease Infective endocarditis (IV drug user)

Question 37

What is the murmur character in mitral stenosis?

Answer 37

Low- rumbling mid-diastolic murmur with opening snap

Question 38

Where is mitral stenosis best heard and where does it radiate to?

Answer 38

Apex in left lateral position | Use bell of stethoscope

Question 39

What is the pathology of mitral stenosis?

Answer 39

Increased resistance between left atrium and left ventricle --> high left atrial pressure --> pulmonary hypertension

Question 40

What are the symptoms of mitral stenosis?

Answer 40

Dyspnoea Fatigue Haemoptysis Chest pain

Question 41

What are the signs of mitral stenosis?

Answer 41

``` Malar flush (due to low cardiac output) Atrial fibrillation Tapping apex (palpable S1) Loud S1 Signs of pulmonary HTN ( RV heave, loud P2) ```

Question 42

What are the causes of mitral stenosis?

Answer 42

Rheumatic heart disease | other causes are rare (congenital, carcinoid)

Question 43

What is the murmur character in mitral stenosis?

Answer 43

Early diastolic (sounds like a breath)

Question 44

Where is mitral stenosis best heard and where does it radiate to?

Answer 44

Upper right sternal edge or lower left sternal edge if sitting forwards

Question 45

What is the pathology of mitral stenosis?

Answer 45

Regurgitation of blood from aorta back into the LV during diastole --> increased LV end-diastolic volume

Question 46

What are the symptoms of mitral stenosis?

Answer 46

Fatigue SOB Palpitations

Question 47

What are the signs of mitral stenosis?

Answer 47

Collapsing pulse Wide pulse pressure Very displaced thrusting apex (volume-loaded) Backflow signs: - Corrigan's (visible carotid pulsation) - de Musset's (head-nodding pulse) - Quincke's (red-coloured-pulsation in nails) +/- Austin Flint murmur (apical diastolic rumble)

Question 48

What are the causes of mitral stenosis?

Answer 48

``` Acute causes: 1. infective endocarditis 2. aortic dissection Chronic causes: 1. Connective tissue disease (e.g. Marfan's, ankylosing spondylitis) 2. Rheumatic heat disease ```