Heart Murmurs

Question 1

Describe an aortic stenosis murmur

Answer 1

• Ejection systolic murmur
• High pitched
• Can often hear an “ejection click”
• Crescendo-decrescendo
• Radiate to carotids

Question 2

• Ejection systolic murmur

- Crescendo-decrescendo

Answer 2

Aortic stenosis

Question 3

What are some symptoms of aortic stenosis?

Answer 3

• Important symptoms are: chest pain, breathlessness and syncope (exertional)
• Patient will also have narrow pulse pressure
• Peripheral pulses are often weak and delayed

Question 4

Name some ejection systolic murmurs

Answer 4

• Aortic stenosis
• Increased flow
• Pregnancy
• ASD
• Severe anaemia
• Pulmonary stenosis

Question 5

Describe a mitral regurgitation murmur

Answer 5

• Pan systolic

- High pitched

Question 6

• Pan-systolic

- High-pitched

Answer 6

Mitral regurgitation

Question 7

Describe a mitral valve prolapse murmur?

Answer 7

• Late systolic

- Mid-systolic ejection click

Question 8

• Late systolic

- Mid-ejection click

Answer 8

Mitral valve prolapse

Question 9

What are some complications of mitral valve prolapse?

Answer 9

Arrhythmias, heart failure, endocarditis

Question 10

Give some examples of a pan-systolic murmur

Answer 10

• Mitral regurgitation
• Tricuspid regurgitation
• Ventricular septal defects

Question 11

Which valves are open and closed in systole?

Answer 11

Aortic open
Mitral shut

Pulmonary open
Tricuspid shut

Question 12

Which valves are open and closed in diastole?

Answer 12

Aortic shut
Mitral open

Pulmonary shut
Tricuspid open

Question 13

Describe an aortic regurgitation murmur

Answer 13

• Early diastolic

- Decrescendo

Question 14

What symptoms are associated with aortic regurgitation?

Answer 14

• Collapsing pulse
• Pulsating fingertips
• Dilated LV with displaced apex beat
• Bounding pulse
• Wide pulse pressure and low diastolic pressure
• Austin Flint murmur

Question 15

How can you describe the features of a murmur (SCRIPT)?

Answer 15

Site - where is the murmur loudest?
Character - Soft? Blowing? Decrescendo? Decrescendo?
Radiation - Carotids (AS)? Axilla (MR)?
Intensity - Grade of murmur?
Pitch - High? Low and grumbling? Indicates velocity
Timing - Systolic? Diastolic?

Question 16

Describe an S3 heart sound

Answer 16

Kentucky S3 (volume overload) Ventricular Gallop

• Early diastole
• Due to impact of inflowing blood against a distended (compliant) ventricle / tensing of chordae tendinae
• Normal in young adults, children, pregnancy and athletes
• Abnormal in the elderly and may signify heart failure, cardiomyopathy, severe mitral or tricuspid regurgitation
• Best heard at cardiac apex
• Should only be heard by bell and faint if not absent with the diaphragm
• Has a low pitch compared to the split S2 which is high-pitched

Question 17

Describe an S4 heart sound

Answer 17

Tennessee S4
Atrial gallop
- Late diastole
- Due to atrial contraction forcing blood into a stiff non-compliant ventricle
- Rarely a normal finding (unlike an S3 heart sound) ie. Always pathological
- Often a sign of diastolic heart failure and severe LV

Question 18

Describe a split S1

Answer 18

• Best heard at tricuspid area
• Caused by mitral and tricuspid valves closing at slightly different times. Usually mitral closes first and then tricuspid
• Usually a normal finding and can be heard in 40-70% of the population
• But S1 can also be found in RBBB. A RBBB causes the electrical impulse to reach the LV before the RV
• Be sure to differentiate between a split S1 and an S4 which is pathologic. S4 heart sound is lower in frequency than S1 whereas in a split S1, the two heart sounds should sound the same

Question 19

Describe a split S2

Answer 19

• Caused by closure of aortic and pulmonary valves
• Can be normally heard during deep inspiration. Decrease in intrathoracic pressure causes increase in venous return to right side of heart and so the RV takes more time during systole to pump blood out of the chamber. Pulmonary valve stays open slightly longer than aortic
• Best heard at pulmonary valve area
• In a normal person, their heart would alternate between a single S2 sound and a split S2 during inspiration
• Compared to S3 (which is later in the cardiac cycle), the split S2 heart sounds are higher in pitch vs. the S3 which is typically lower in pitch

Question 20

Describe common and/or important underlying causes of heart murmurs

Answer 20

Pregnancy - increased stroke volume can cause murmur

Rheumatic heart disease – heart valves become inflamed and scarred over time

Infective endocarditis – heart valves are not directly supplied by blood so white blood cells cannot reach them and bacteria can grow

Myocardial infarction with rupture of papillary muscles – will cause AV valve regurgitation

Valve prolapse – will also cause AV valve regurgitation?

Calcific degeneration – will cause stenosis

Congenital bicuspid valve – aortic valve only has 2 leaflets, can cause both stenosis and regurgitation

Congenital aortic stenosis

Aortic dilatation from syphilis – happens in tertiary stage of syphilis, begins as inflammation of outermost layer of the blood vessel. Causes aortic regurgitation

Ankylosing spondylitis - aortic insufficiency, aortitis at the ascending aorta, atrioventricular (AV) block, or branch block

Marfan’s syndrome - aorta can become stretchedandmay tear (aortic dissection) or burst (aortic rupture)

Question 21

What investigations would you do?

Answer 21

ECG – may show ST changes, may show axis deviation due to ventricular hypertrophy

Echocardiogram

CXR – may show cardiomegaly

M-mode and 2-dimensional imaging??

Colour flow doppler

Pulsed wave doppler

Continuous wave doppler

Could also consider: radionuclide angiography, MRI, exercise stress testing, cardiac catheterisiation