Heart murmurs and sounds Flashcards
What is S1 caused by and what does it indicate?
Closure of mitral and tricuspid valves
Marks the start of ventricular systole
What is S2 caused by and what does it indicate?
Closure of aortic and pulmonary valves
Marks end of ventricular systole and the start of diastole
Why is S2 not always heard as one discrete sound and sometimes split?
Pulmonary valve may close just after aortic valve
Closure of pulmonary valve just after the aortic valve is prolonged during inspiration, or in defects which cause more blood to be pumped out of the right ventricle
What is a thrill?
Palpable vibration caused by turbulent blood flow through a heart valve
Murmur associated with aortic stenosis and where is it loudest
Ejection systolic murmur
‘Crescendo-decrescendo’
Radiates to carotid arteries
Heard loudest over aortic valve
Causes of aortic stenosis
Calcification of aortic valves(most common)
Congenital abnormality of aortic valve(bicuspid aortic valve)
Rheumatic heart disease(rare)
Clinical features of aortic stenosis not linked to murmur
Slow rising pulse with narrow pulse pressure
Non-displaced, heaving apex beat(indicates LVH)
Reduced or absent S2
Reverse splitting of S2
Murmur associated with mitral regurg
Pansystolic murmur heard loudest over mitral area and radiates to the axilla
Causes of mitral regurg
Infective endocarditis Acute MI with rupture of papillary muscles Rheumatic heart disease Congenital defects of mitral valve Cardiomyopathy
Clinical features of mitral regurg
Heard loudest using the bell of the stethoscope
Loudest on expiration in the left lateral decubitus position
Displaced, hyperdynamic apex beat
Murmur associated with aortic regurgitation
Decrescendo early diastolic murmur heard loudest at left sternal edge
Causes of aortic regurg linked to valve pathology
Congenital bicuspid aortic valve
Rheumatic heart disease
Infective endocarditis
Causes of aortic regurg linked to aortic root dilatation
Aortic dissection
Connective tissue diseases(e.g. marfan’s)
Aortitis
Clinical features associated with aortic regurg
Austin flint murmur
Collapsing pulse
Displaced, hyperdynamic apex beat
What is an Austin Flint murmur
Low pitched rumbling mid-diastolic murmur at apex
What is an austin flint murmur caused by
Caused by regurgitated blood through the aortic valve mixing with blood from left atrium during atrial contraction
Sign of severe aortic regurg
Murmur associated with mitral stenosis
Associated with a low-pitched, rumbling, mid-diastolic murmur heard loudest over the apex
Causes of mitral stenosis
Rheumatic heart disease(most common)
Congenital
Clinical features of mitral stenosis
Loudest in left lateral decubitus position on expiration
Low-volume pulse
Loud first heart sound with tapping apex beat
Malar flush
Arrhythmia associated with mitral stenosis
Atrial fibrillation
Murmur associated with mitral valve prolapse
Associated with a combination of a mid-systolic click and mid to late-systolic murmur
What is primary mitral valve prolapse caused by
Myxomatous degeneration of the mitral valve and is associated with connective tissue diseases
Murmur associated with tricuspid regurg
Pansystolic murmur heard loudest over the tricuspid region
Causes of tricuspid regurg
Right ventricular dilatation Rheumatic fever Infective endocarditis Carcinoid syndrome Congenital(ASD, Ebstein)
What is the ebstein anomaly
Abnormal attachment of tricuspid valve leaflets which causes the tricuspid valve to displace downwards into the right ventricle
Clinical features of tricuspid regurg
Large ‘v-waves’ visible in the jugular veins(caused by right atrial filling against a closed tricuspid valve)
Visible/palpable hepatic pulsations
Signs of right-sided heart failure
Signs of right-sided heart failure
Right ventricular heave
Peripheral oedema
Hepatomegaly
Ascites
Murmur associated with pulmonary stenosis
Ejection systolic murmur heard loudest over pulmonary area
Radiates to left shoulder/left infraclavicular region
Causes of pulmonary stenosis
Congenital
Rheumatic fever
Carcinoid syndrome
Congenital causes of pulmonary stenosis
Turner’s
Noonan’s
Williams
Tetralogy of fallot
Clinical features of pulmonary stenosis
Prominent ‘a waves’ in jugular veins
Widely split S2
Right ventricular dilatation may lead to signs of right-sided heart failure
Clinical features of pulmonary regurg
Early decrescendo murmur heard loudest over the left sternal edge
Loudest during inspiration
Usually due to pulmonary hypertension(graham steell murmur)
Causes of pulmonary regurgitation
Pulmonary hypertension
Infective endocarditis
Congenital valvular heart disease
Murmur associated with tricuspid stenosis
Soft diastolic murmur loudest at 3rd-5th intercostal space at the left sternal edge
Causes of tricuspid stenosis
Rheumatic fever(most common) Congenital disease Infective endocarditis
Clinical features of tricuspid stenosis
Raised JVP with giant ‘a waves’
Peripheral oedema
Ascites
What are congenital VSDs often associated with
chromosomal disorders:
Down’s syndrome
Edward’s syndrome
Patau syndrome
cri-du-chat syndrome
Acquired cause of VSD
Post MI
Post-natal VSD presentation
failure to thrive
features of heart failure hepatomegaly tachypnoea tachycardia pallor
classically a pan-systolic murmur which is louder in smaller defects
Mx of VSD
small VSDs which are asymptomatic often close spontaneously are simply require monitoring
moderate to large VSDs usually result in a degree of heart failure in the first few months
nutritional support
medication for heart failure e.g. diuretics
surgical closure of the defect
Complications of VSD
Aortic regurgitation Infective endocarditis Eisenmger's complex Right heart failure Pulmonary hypertension
What is coarctation of the aorta
Congenital narrowing of the descending aorta
Features of aortic coarctation
infancy: heart failure
adult: hypertension
radio-femoral delay
apical click from the aortic valve
notching of the inferior border of the ribs (due to collateral vessels) is not seen in young children
Murmur associated with aortic coarctation
Mid systolic murmur, maximal over back
Aortic coarctation associations
Turner’s syndrome
bicuspid aortic valve
berry aneurysms
neurofibromatosis
What might be seen on CXR in mitral stenosis
Left atrial enlargement
What is a corrigan pulse/water-hammer pulse
Pulse that is forceful and then suddenly collapses usually found in patients with aortic regurg
