Heart Murmurs Flashcards
Describe an aortic stenosis murmur
- Ejection systolic murmur
- High pitched
- Can often hear an “ejection click”
- Crescendo-decrescendo
- Radiate to carotids
- Ejection systolic murmur
- Crescendo-decrescendo
Aortic stenosis
What are some symptoms of aortic stenosis?
- Important symptoms are: chest pain, breathlessness and syncope (exertional)
- Patient will also have narrow pulse pressure
- Peripheral pulses are often weak and delayed
Name some ejection systolic murmurs
- Aortic stenosis
- Increased flow
- Pregnancy
- ASD
- Severe anaemia
- Pulmonary stenosis
Describe a mitral regurgitation murmur
- Pan systolic
- High pitched
- Pan-systolic
- High-pitched
Mitral regurgitation
Describe a mitral valve prolapse murmur?
- Late systolic
- Mid-systolic ejection click
- Late systolic
- Mid-ejection click
Mitral valve prolapse
What are some complications of mitral valve prolapse?
Arrhythmias, heart failure, endocarditis
Give some examples of a pan-systolic murmur
- Mitral regurgitation
- Tricuspid regurgitation
- Ventricular septal defects
Which valves are open and closed in systole?
Aortic open
Mitral shut
Pulmonary open
Tricuspid shut
Which valves are open and closed in diastole?
Aortic shut
Mitral open
Pulmonary shut
Tricuspid open
Describe an aortic regurgitation murmur
- Early diastolic
- Decrescendo
What symptoms are associated with aortic regurgitation?
- Collapsing pulse
- Pulsating fingertips
- Dilated LV with displaced apex beat
- Bounding pulse
- Wide pulse pressure and low diastolic pressure
- Austin Flint murmur
How can you describe the features of a murmur (SCRIPT)?
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?
Describe an S3 heart sound
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
Describe an S4 heart sound
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
Describe a split S1
- 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
Describe a split S2
- 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
Describe common and/or important underlying causes of heart murmurs
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)
What investigations would you do?
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
