Heart Murmurs and Congenital Heart Disease - Dolphens Flashcards
Coarctation of Aorta
Review specific heart disease that present as a murmur in children, including: Coarctation
- Systolic ejection murmur in midback, also LUSB
- May have continuous murmur in back (older)
- Increased BP in arms
- Lower BP with weak to absent pulses in legs
- LV heave
- RVH (infant) or LVH (older) on EKG
- May have cardiomegaly, abnormal aortic contour, or rib notching on CXR
Aortic Stenosis
Describe the common adult heart murmurs associated with AS, AR, MS, and MR.
- most common fatal valvular heart lesion
- cause: degenerative calcification
- age: typically 60+
- long latent period prior to symptoms
symptoms (prognosis):
- angina (5 years)
- syncope (3 years)
- heart failure (2 years)
harsh, mid-systolic ejection murmur
best heard: aortic area
diagnostic studies
- ECG: LVH, LBBB
- CXR: aortic valve calcification
- Echo: determine LV dimensions, pressure gradient, estimate valve area and ejection fraction
tx: valve replacement
Mitral Regurgitation
Describe the common adult heart murmurs associated with AS, AR, MS, and MR.
Causes
- mitral vavle prolapse
- ischemic heart disease
- cardiomyopathy
- infective endocarditis
- connective tissue disorders
- congenital defect
- trauma
Chronic
- asymptomatic
- fatigue and mild dyspnea on exertion
- progresses to DOE, PND, PE, hemoptysis
Acute
- symptomatic
- LHF - DOE, PND, pulmonary congestion, cardiogenic shock
Murmur
- holosystolic
- blowing
- heard at apex, radiates to axilla
- no changes in intensity
Diagnostics
- ECG: LA enlargment, LV/RV hypertrophy
- CXR: LA and LV enlargment
- Echo: confirms dx, chamber dimensions, LA/LV function
Management
- ACE inhibitors
- surgery in symptomatic patient, EF below 50%
Small Ventricular Septal Defect
Review specific heart disease that present as a murmur in children, including: VSD
- most common form of CHD
- typically close by 1 year
- inverse relationship with newborns age
- no SBE prophylaxis
Murmur
- High-pitched Holosystolic murmur @ LMSB to LLSB
- May or may not have a thrill
- Generally no LV heave or RV lift
- Normal S2
- No diastolic murmur
- Normal EKG and chest x-ray
Large Ventricular Septal Defect
Review specific heart disease that present as a murmur in children, including: VSD
- perimembranous or membranous
- pulmonary overcirculation
- often require surgical closure 4-6 months
Murmur
- Low pitched Holosystolic murmur @ LMSB to LLSB
- Diastolic flow rumble @ apex
- Increased precordial activity
- Increased P2 intensity
- May have RVH +/- LVH on EKG
- May have cardiomegaly and pulmonary plethora on x-ray
Atrial Septal Defect
Review specific heart disease that present as a murmur in children, including: ASD
- usually asymptomatic - no murmur
- rSR’ pattern on EKG
- recommend closure when large or RA and RV enlargment
- no SBE prophylaxis
Murmur
- Systolic ejection murmur @ LUSB
- Diastolic flow rumble @ LLSB
- No palpable thrill
- RV heave
- Fixed Split S2
- May have RVH on EKG
- May have cardiomegaly and pulmonary plethora on x-ray
Innocent Murmurs: Pulmonary Branch Murmur of Infancy
Describe the evaluation of heart murmurs in children, being able to differentiate between pathologic and innocent murmurs: branch pulmonary stenosis
Timing: Systolic ejection
Intensity: 1-3/6
Location: LUSB, RUSB, to axillae and back
Pitch: Medium
Character: Blowing
Helpful Maneuvers: None
Innocent Murmurs: Venous Hum
Describe the evaluation of heart murmurs in children, being able to differentiate between pathologic and innocent murmurs: venous hum
Timing: Continuous
Intensity: 1-3/6
Location: RUSB, occasionally LUSB
Pitch: Medium
Character: Machinery-like
Helpful Maneuvers: Supine to sitting, Head position, Compression of jugular vein
Innocent Murmurs: Pulmonary Flow Murmur
Describe the evaluation of heart murmurs in children, being able to differentiate between pathologic and innocent murmurs: pulmonary flow murmur
Timing: Systolic ejection
Intensity: 1-3/6
Location: LUSB
Pitch: Low to medium
Character: Blowing
Helpful Maneuvers: Inspiration, Standing
Aortic Stenosis
Review specific heart disease that present as a murmur in children, including: Aortic Stenosis
- Bicuspid Aortic Valve
- No SBE prophylaxis
Murmur
- Systolic ejection murmur @ RUSB to Neck
- May have thrill @ RUSB or SSN
- Usually with ejection click
- May have LV heave
- May have assoc diastolic murmur if valve leaks
- May have LVH on EKG
- May have cardiomegaly, or prominent aortic shadow on x-ray
Aortic Regurgitation
Describe the common adult heart murmurs associated with AS, AR, MS, and MR.
Chronic - asymptomatic for decades
- degnerative disorders
- dilation of ascending aorta
- bicuspid aortic valve
- rheumatic fever
- syphilis
- connective tissue disorder
Acute - develop LV failure abruptly resulting in symptoms
- aortic dissection
- infective endocarditis
- trauma
- valve rupture
- hypertension
high frequency blowing decrescendo diastolic murmur along LSB
high pulse pressure
echo: valve morphology, LV dimension, aortic root size, ejection fraction
tx: surgery when ejection fraction below 55%
Mitral Disease
- require ACE inhibitor and anti-arrhythmic
- no SBE prophylaxis
Murmur
- Non-ejection Click, Late Systolic Murmur
- May have Diastolic Rumble @ Apex
- May have of Palpitations, Arrhythmias,
- Chest Pain
- May have Nonspecific ST-T Wave Changes
- May have Cardiomegaly on CXR
- May have LVH or LAE on EKG
- Marfan, Ehlers-Danlos, Stickler’s, Fragile X, Connective Tissue Syndromes
Diagnostic Criteria for Innocent Murmur
Understand how to identify innocent vs. pathologic murmurs murmurs
- classic findings for a specific innocent murmur
- grade 1/2, changes with position, LLSB
- no history/complaints to suggest disease
- no additional physical findings to suggest disease
Mitral Stenosis
Describe the common adult heart murmurs associated with AS, AR, MS, and MR.
sequela of rheumatic heart disease develops years-decades after rheumatic fever
clinical features:
- chronic fatigue - low cardiac output
- decreased exercise tolerance
- SOB
- orthopnea
- hemoptysis
- palpitations
exam
- opening snap with diastolic rumble heard at apex
- loud S1 and P2
- JVD
- edema, hepatic congestion
treatment
- heart rate control
- diuretics if pulmonary congestion
- warfarin if atrial fibrillation
- surgery: ballon valvotomy or valvuloplasty
Patent Ductus Arteriosus
Review specific heart disease that present as a murmur in children, including: PDA
- very common
- increased incidence in premature babies
- tx: surgical ligation, device, coil
- no SBE prophylaxis
Murmur
- Continuous murmur @ LUSB to left infraclavicular region
- Wide pulse pressure, bounding pulses
- May have increased LV impulse
- Largest may have diastolic thrill @ LUSB
- May have LVH on EKG
- May have cardiomegaly and pulmonary plethora on x-ray
