Heart murmurs and dysrhythmias Flashcards
What is infective endocarditis (IE)?
Caused by microbial infection (bacterial) within the endothelium of the heart → vegetations form and adhere to endothelial structures
- Heart valves must often affected
What are the three classifications of IE?
Acute → death occurs within days to <6 weeks
Subacute → death occurs within 6 weeks to 3 months
Chronic → death occurring later than 3 months
Causes of IE
- Native valve endocarditis (most common)
- Prosthetic valve endocarditis
- Injection drug users
- Healthcare associated endocarditis
- Symptoms within 48 hours of hospital admission
- Cardiac implantable device
IE clinical presentation
- Generalized fatigue, malaise, weakness
- Night sweats
- Fever, chills
- Weight loss, anorexia
- N/V
- S. aureus infection → abrupt onset that prompts the patient to seek early medical attention
IE physical examination
- Heart murmurs
- Cerebral emboli can lead to neurologic findings → headache, CN involvement
- Roth spots in eyes, changes in visual acuity
- Osler nodes: painful nodules on fingers and toe pads
- Janeway lesions: non tender, hemorrhagic macules on palms and soles of feet
- Splinter hemorrhages on nails
IE diagnostic studies
- Three blood cultures from different venipuncture sites
- CBC w/ diff, RF, circulating immune complexes
- BUN, creatinine
- UA
- Chest x-ray
- EKG
- Echocardiogram
True/false: Specialty consultation and immediate referral to the ED is warranted for patients presenting with fever and suspicion of IE
True
IE management
- Antibiotics (based on culture/sensitivity)
- Prophylaxis before dental procedures → amoxicillin 2 g 30-60 minutes before procedure
- Repeat blood cultures after treatment
- Work with specialist (ID, cardiology, cardiac surgery)
IE surgery indications
- Failure of antibiotic therapy
- Development of refectory CHF
Antibiotic alternatives for IE management if patients are allergic to amoxicillin
- Cephalexin
- Clindamycin
- Azithromycin
- Clarithromycin
What factors help providers distinguish murmurs from one another?
- Timing (most important)
- Delineates division between systolic and diastolic murmurs
- Location
- Radiation
- Intensity (Grade)
- Quality
- Pitch
What mnemonic is helpful in identifying the features of murmurs?
SCRIPTS + response to physiologic maneuver
Site (location)
Character (quality)
Radiation
Intensity (grade)
Pitch
Timing
Shape
+
Response to physiologic maneuver
Grades I through III of murmurs
- Grade I → barely audible
- Grade II → soft but easily heart
- Grade III → loud
Grades IV through VI of murmurs
- Grade IV → loud and associated with a thrill
- Grade V → audible with the stethoscope barely touching the chest
- Grade VI → audible without a stethoscope
How would you distinguish a systolic from diastolic murmur with palpation?
If you put your fingers on the carotid and hear the murmur at the same time you feel a pulse = systolic
What seven valvular/heart defects are considered a systolic murmur?
Please sneak away slowly, Mr. Tiger
- Pulmonic stenosis
- Aortic stenosis
- Mitral regurgitation
- Tricuspid regurgitation
Plus
- Ventricular septal defect (VSD)
- Hypertrophic cardiomyopathy
- Benign or innocent murmurs
Do diastolic murmurs have a good prognosis?
Diastolic murmurs are not good
- Will always involve cardiology
What five valvular/heart defects are considered diastolic murmurs?
Arms parts
- Aortic regurgitation
- Mitral stenosis
- Pulmonic regurgitation
- Tricuspid stenosis
Continuous murmurs
- Patent ductus arteriosus (PDA)
Common complaints associated with valvular disorders
- Chest pain
- Palpitations
- Dizziness
- Syncope or near syncope
- Fatigue
- Exercise intolerance
- Dyspnea
Physical examination components when assessing patients with valvular heart defects
- Inspection and palpitation of chest wall
- PMI, heaves, lifts, thrills
- Auscultation of S1, S2, S3, S4, murmurs
- Position change noted (squatting/standing)
Valvular heart defect diagnostic studies
- EKG
- Chest x-ray
- Transthoracic echocardiogram (TTE) with 2D imaging and doppler
- Stress test
- Cardiac catheterization
What test is the gold standard test for initial evaluation of patients with suspected/known VHD?
Transthoracic echocardiogram (TTE)
General VHD management
- Aortic valve replacement (AVR)
- Surgical replacement and transcatheter aortic valve replacement (TAVR)
Pharmacologic therapy for patients with mitral regurgitation
- Beta blocker
- ACE inhibitors or ARBs
- Aldosterone antagonist
- Vasodilator therapy
- Anticoagulation
What is characteristic of an aortic stenosis murmur?
Harsh, crescendo-decrescendo
What is a common cause of aortic stenosis?
Rheumatic fever (2nd most common cause)
- Mitral valve is usually involved
What is the usual course (progression) of aortic stenosis?
Prolonged asymptomatic period (until 5th or 6th decade of life) then rapid deterioration at onset of symptoms
Common associated symptoms of aortic stenosis
- Angina
- Syncope → exertion, preceded by dizziness
- HF (LV will enlarge and fail) → dyspnea
Aortic stenosis physical exam findings
- Squatting increases murmur, standing resolves it
- Loudest at right upper sternal border and carotids (will hear murmur at the same time)
- Narrow pulse pressure (systolic - diastolic pressure)
- ECG and chest x-ray normal
- Cardiomegaly appears late on echo
What is characteristic of an aortic regurgitation murmur?
Loud, blowing, high pitched
What is the usual course (progression) of aortic regurgitation?
Prolonged asymptomatic period even with exertion, then will develop decreased exercise tolerance
- Very late course will lead to CHF
Aortic regurgitation clinical presentation
- Angina
- CHF
- Dizziness
- Atypical chest pain (aware of heartbeat and pounding when lying down)
- Palpitations d/t tachycardia or premature heartbeats
Aortic regurgitation physical exam findings
- Murmur heard best with patient in seated position slightly leaning forward and breath held after expiration
- Water hammer pulse → bounding and forceful, wide and quick
- PMI displaced downward and to the left
Aortic regurgitation imaging findings
- X-ray → late findings demonstrate large and dilated LV
- EKG → LVH
What is the most common cause of mitral stenosis?
Rheumatic fever
What is characteristic of a mitral stenosis murmur?
Low pitched, diastolic rumble
Mitral stenosis symptoms
- Dyspnea (most common)
- Atrial fibrillation → risk for thrombus formation
- Hemoptysis
- Right ventricular hypertrophy
Mitral stenosis physical exam findings
- Loud S1
- Apical diastolic murmur that radiates toward the axilla
- Chest x-ray → enlarged left atrium
- EKG → atrial fibrillation
What is characteristic of a mitral regurgitation murmur?
Pansystolic (holosystolic) blowing, musical
Most common cause of mitral regurgitation
Mitral valve prolapse
Mitra regurgitation physical exam findings
- PMI displaced laterally
- Murmur heard at apex with radiation to axilla and sternum (grade 2+)
- Chest x-ray → LV and left atrium enlargement
- EKG → atrial fibrillation
What is characteristic of a mitral valve prolapse murmur?
Late systolic, honking, mid systolic “click”
What is the most common VHD that predisposes patients to infective endocarditis?
Mitral valve prolapse
Mitral valve prolapse symptoms
- Palpitations (PACs, PVCs more common with exercise)
- Chest pain → severe stabbing pain at apex
- Dyspnea
- Dizziness
- Numbness
Mitral valve prolapse physical exam findings
- Mid systolic “click” at apex and left sternal border
- Late systolic click (later in course)
- Worse with standing
- Quieter with squatting
What is the difference between aortic stenosis and MVP in terms of making the murmur better or worse?
AS → squatting makes the murmur worse (louder)
MVP → squatting makes the murmur quieter
True/false: CHD is the leading cause of morbidity and mortality within the first year of life in infants
True
- Developmental alterations leading to CHD occur in the 2nd or 8th weeks of gestation
If left to right shunting in CHD cyanotic or acyanotic?
Acyanotic → oxygenated blood from the left side of the heart goes to the right due to higher pressures
- Blood is still oxygenated before it does to systemic circulation
What are the three left-to-right shunts (acyanotic)?
- Atrial septal defect (foramen ovale)
- Ventricular septal defect
- PDA
- Persistent connection between the aorta and pulmonary artery
Atrial septal defect (foramen ovale) symptoms
Symptoms become more common in late adolescence or early childhood
- Fatigue
- Exertional dyspnea
- Frequent URIs or PNA
Atrial septal defect physical exam findings
- Murmur heard at 2-3 years old
- Mild left anterior chest bulge or palpable lift at left sternal border
- Wide split S2
Atrial septal defect (foramen ovale) management
- Small defects close spontaneously and larger defects require intervention
True/false: Majority of ventricular septal defects close spontaneously by age 4
True
Ventricular septal defect symptoms
Symptoms began at 6 months
- Small defect may be asymptomatic at birth
Ventricular septal defect physical exam findings
- Small VSD
Harsh, high pitched, grade II-IV/VI holosystolic murmur at LLSB
Ventricular septal defect physical exam findings
- Large VSD
- Low pitched, grade II-V/VI holosystolic murmur at LLSB
- Diastolic hum at apex
- Thrill along LSB
- S3 and S4 gallop if CHF present
Ventricular septal defect management
- Infants with small defects and no CHF symptoms can be monitored every 6 months for the first year of life, then every other year
- Larger defects with symptoms of CHF require meds, SBE prophylaxis, proper nutrition, surgery
PDA clinical findings
- Asymptomatic if PDA is small
- Symptoms of CHF may be present in the first week of life in larger PDAs (evident by 3 months)
What is characteristic of a PDA murmur?
Machine like murmur
- Normal closure occurs in the first 12-72 hours after birth
- Permanent closure in 2-3 weeks in term infants
PDA physical exam findings
- Postnatal period → soft systolic murmur heard along LSB, under clavicle, and in the back
- After first week of life: harsh, rumbling, continuous machinery murmur at left intraclavicular fossa
- Thrill at base
PDA management
- Large shunts require surgery
- Indomethacin or ibuprofen given to preterm infants to encourage closure
- Asymptomatic infants with small PDA followed for spontaneous closure or transcatheter device closure
What are the three right-to-left shunts (cyanotic)?
Unoxygenated blood goes from the right to left side of the heart then to systemic circulation
- Tetralogy of fallot
- Transposition of the great arteries
- Tricuspid atresia
What is tetralogy of fallot? What defects are associated with this?
Combination of four anatomic cardiac defects → right ventricular outflow tract obstruction
- Pulmonary valve stenosis
- Right ventricular hypertrophy
- VSD
- Aorta that overrides the ventricular septum
Tetralogy of fallot clinical findings
Depends on the degree of right ventricular outflow obstruction and presence of PDA
- Cyanosis
- Dyspnea (“TET” spells)
- Poor weight gain
Tetralogy of fallot physical exam findings
- Cyanosis
- Dyspnea
- Harsh systolic ejection murmur at left mid to upper sternal border
- Holosystolic murmur at LLSB
- Sternal lift
- Palpable thrill
Tetralogy of fallot management
- Surgery (not compatible with life)
- TET spell management → Cradled in knee-chest position, soothed, given supplemental oxygen or morphine sulfate SQ
What is transposition of the great arteries?
Aorta is at the RV and pulmonary artery is at the LV (opposites)
- Incomplete septation and migration of the truncus arteriosus during fetal development
Transposition of the great arteries clinical findings
- Cyanosis within 1 hour of birth
- CHF symptoms
- Large for gestational age infants
Transposition of the great arteries management
Immediate referral to cardiac care center
What is tricuspid atresia?
Small right ventricle without access from the right atrium
- Transposition of the great arteries occur in 50% of these patients
Tricuspid atresia clinical findings
- Cyanosis
- Increased respiratory rate
- Fatigue with effort of crying or feeding
- Poor weight gain
Tricuspid atresia physical exam findings
- Early systolic murmur
- Single S2
- Cyanosis
- Hepatomegaly
Tricuspid atresia management
Specialist involvement
What is an example of an obstructive cardiac lesion?
Coarctation of the aorta
- Narrowing of a small or large segment of the aorta
Coarctation of the aorta clinical findings
- Apparent at 6 weeks with tachypnea, poor feeding, cool lower extremities
- At 3-5 years old, will have HTN and murmur
Coarctation of the aorta physical exam findings
- Upper extremity HTN with lower extremity hypotension
- Absent or wear distal pulses
- Bounding brachial, radial, carotid pulses
- Symptoms of CHF
- Systolic ejection murmur in left infraclavicular region with transmission to back
- Palpable ventricular heave at apex
- Gallop rhythm
