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IPE revision CARDIOLOGY > heart sounds and murmurs > Flashcards

heart sounds and murmurs Flashcards

1
Q

what do the normal heart sounds of the heart correspond to?

A

S1 (Lub) = mitral and tricuspid valve closure

S2 (Dub) = Aortic and pulmonary valve closure

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2
Q

why is S2 often split?

A

On inspiration pulmonary valve closes shortly after aortic valve due to the pressure in the lungs

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3
Q

what can a quiet S1 or S2 indicate?

A

Pericardial effusion and Tamponade

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4
Q

what causes the 3rd heart sound?

A

blood rushing into the ventricles filling them rapidly and the ventricles reaching their full elastic potential therefore suddenly stopping the blood flow leads to S3

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5
Q

what is 3rd heart sound a sign of?

A

**NB can be normal in young children/adults up to 30

Heart Failure - dilated ventricles, less elasticity

MI - dilation and less elasticity (inc collagen)

Cardiomyopathy - dilation or less elasticity

HTN - hypertrophic wall, smaller ventricular lumen

constrictive pericarditis - Ventricle restricted

aortic regurg - blood flow back to ventricles, fill quickly

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6
Q

what causes the 4th heart sound?

A

Atria trying to contract against non-compliant ventricles

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7
Q

what is the 4th heart sound a sign of?

A

** always pathological

HF - hypertrophy (diastolic)

Cardiomyopathy - Hypertropic

Post-MI

HTN - hypertrophy

aortic stenosis

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8
Q

what causes exaggerated splitting of S2 - pathological splitting?

A

Early closure of aortic = mitral regurg, VSD

Late closure of pulmonary = pulmonary stenosis, ASD

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9
Q

what can cause splitting of S2 to widen on expiration?

A

Aortic stenosis or PDA

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10
Q

state the different systolic and diastolic murmurs

A

Systolic:

  • Tricuspid regurgitation
  • Pulmonary stenosis
  • Mitral Regurg
  • Aortic Stenosis

Diastolic:

  • Tricuspid Stenosis
  • Pulmonary Regurg
  • Mitral Stenosis
  • Aortic Regurg

Continuous Murmur:
- PDA

Pan-systolic:
- VSD

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11
Q

how are systolic murmurs graded?

A 
1 = very faint
2 = quiet, but heard immediately steth on chest
3 = moderately loud
4 = very loud with palpable thrill
5 = extremely loud with palpable thrill
6 = extremely loud with thrill and heard with steth not on chest
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12
Q

what are the causes of mitral stenosis

A
  1. Calcification with Age
  2. Rheumatic Fever
  3. Congenital
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13
Q

what Ix could you do for someone with a murmur?

A

Routine blood - FBC (anaemia), U&E (hyperK), TFT

ECG - look for signs of arrhythmias (AF), bifid P waves (p mitrale)

ECHO - view the valves

CXR - look at lungs for complications e.g. oedema

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14
Q

what ECG changes are seen in mitral stenosis?

A

bifid p waves (p mitrale) - due to RA contraction slightly before LA contraction,
potential AF

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15
Q

list the signs and symptoms of mitral stenosis

A

Malar flush - due to inc CO2 causing vasodilation

Murmur - rumbling mid-diastolic, best heart in axilla on held-expiration with bell

Tapping apex beat - mitral valves close late due to high atrial pressure

Loud S1 - because valves close together

Signs of LHF - heave, orthopnoea, dyspnoea

Signs of RHF - raised JVP, peripheral oedema

fatigue - due to low CO

complications of having large LA = dysphagia, hoarseness of voice

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16
Q

how can we manage mitral stenosis

A

mild - diuretics + anticoagulants + AF management

moderate = Valvulopasty (stent) and valvectomy (shaving)

severe = Valve replacement

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17
Q

what are the CXR changes in mitral stenosis?

A

Left atria enlargement

  • straight left cardiac margin (normally concave)
  • double contour right margin (LA and RV can be seen separate)

Signs of RHF:

  • pulmonary oedema
  • Kurley B lines
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18
Q

what are the indications of severe mitral stenosis

A

malar flush,
longer murmur,
opening snap is closer to S2,
signs of right HF,

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19
Q

what are the causes of mitral regurgitation

A
  1. Infective endocarditis
  2. Rheumatic fever
  3. Cardiomyopathy- dilated
  4. Barlow’s syndrome
  5. LV dilation - pulls apart mitral valves post MI
  6. Papillary muscle rupture - post-MI
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20
Q

what is barlows syndrome? complications of this

A

Also known as ‘prolapsing mitral valve’
congenital condition associated with marfans, ASD, VSD, turners and osteogenesis imperfect

complications inc: mitral regurg, cerebral emboli and arrhythmias

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21
Q

what ecg changes are seen in mitral regurgitation

A 
P mitrale (bifid p waves)
may see signs of AF
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22
Q

how is mitral regurgitation managed?

A

begin with = diuretics, anticoagulants and manage AF

more severe = valve replacement

23
Q

what are the signs and symptoms of mitral regurgitation?

A

Pansystolic murmur - heard best in left axilla on expiration with the diaphragm

Malar flush - CO2 retention

displaced apex beat

Splitting of S2

Quiet S1

Signs of LHF - dyspnoea, orthopnoea, fatigue, palpitations

complications of having large LA = dysphagia, hoarseness of voice

24
Q

what indicates severe mitral regurgitation?

A

larger the LV
decompensated LV failure
AF

25
Q

what CXR changes are seen in mitral regurgitation

A

Cardiomegaly (due to LV dilation)
double contoured right margin
signs of HF

26
Q

what are the causes of aortic stenosis

A
  1. calcification with age
  2. bicuspid aortic valves (congenital - Williams syndrome)
  3. rheumatic fever
27
Q

what are the ECG changes seen in aortic stenosis

A

Tall QRS complexes
left axis deviation
LV strain pattern (ST depression in V5, V6, I and aVL)

28
Q

how is aortic stenosis managed?

A

Surgery (open) valve replacement ideally, however if not surgically fit then can do TAVI (trans-aortic valve implant) or valvuloplasty

TAVI = up femoral, through aorta to replace valve

29
Q

what is contraindicated in aortic stenosis?

A

The use of GTN or ACEi as both cause vasodilation when CO is already low
Exercise stress test

30
Q

what is the symptomatic triad seen in aortic stenosis?

A

Signs of heart failure - breathlessness on exertion
Syncope on exertion
Signs of angina on exertion

31
Q

what are the signs of aortic stenosis?

A

Ejection systolic murmur - can be made louder by asking the patient to sit forward and listen on left sternal margin also radiates to carotids

Slow rising, low volume pulse
narrow pulse pressure

S4 heart sound

forceful apex beat

signs of heart failure

cool peripheries

32
Q

what are the indications for severe aortic stenosis?

A

S4 heart sound

ECHO:

  • pressure gradient >40mmHg
  • jet velocity >4m/s
  • valve area <1cm2

Decompensated left heart failure

narrow pulse pressure

33
Q

what are the CXR signs seen in aortic stenosis

A

Increased size of LV
Dilated aorta/arch
Signs of HF if present
may also see calcifications

34
Q

what are the complications of aortic stenosis?

A

Death
Heart failure
MI

35
Q

what are possible differentials of aortic stenosis ?

A

Aortic sclerosis - thickening but no stenosis (get murmur but no change in pulse or radiation to carotids)

HOCM: - angina and ejection systolic murmur

36
Q

what are the causes of aortic regurgitation?

A 
mnemonic REAM
R = rheumatic fever, RA
E = endocarditis
A = AS, aortic dissection
M = marfans

Others - bicuspid aortic valve, ehlers danlos, tertiary syphillis

37
Q

what are the signs of aortic regurgitation

A

Early diastolic murmur - on expiration sitting forward increases sound

Wide pulse pressure, collapsing pulse
large volume

Shifted apex beat

S3 heart sound

signs of heart failure

severe AR Austin Flint murmur - rumbling mid-diastolic murmur at the apex due to regurgitating blood causing valve flutter

Signs:
Corrigans - carotid pulse best seen arm above head
Quinke’s - capillary pulsation in nail bed
De mussets - head nodding each heart beat
pistol shot femorals - sharp bang on each heart beat

38
Q

what are the symptoms of aortic regurgitation

A

symptoms of HF = PND, orthopnoea, fatigue

exertional dyspnoea

syncope, angina

palpitations / arrhythmias (esp AF)

39
Q

what is the management of aortic regurgitation ?

A

ACEi and Ca blockers to reduce strain

valve replacement in severe disease

ECHO every 6-12 months

40
Q

what indicates severe Aortic regurgitation?

A 
S3 heart sound
long murmur
Wide pulse pressure and collapsing
Austin flint murmur
decompensated LVF
41
Q

how is a collapsing pulse assessed?

A

find radial pulse then raise above patients head, the collapsing will be exaggerated

42
Q

what are the CXR changes in aortic regurgitation?

A

LV dilation / cardiomegaly
dilated ascending aorta
signs of HF if present

43
Q

what are the causes of tricuspid regurgitation

A
  1. IE
  2. RF
  3. RA dilation
  4. Congenital
44
Q

what are the signs and symptoms of tricuspid regurgitation

A

Mid systolic murmur

Signs of RH failure - ascites, raised JVP, peripheral oedema

Hepatic pain on exertion

pulsatile hepatomegaly

RV heave

45
Q

what are the causes of tricuspid stenosis

A
  1. IE
  2. congenital
  3. RF
46
Q

what murmur is heard in tricuspid stenosis

A

Early-diastolic loudest on inspiration

47
Q

what are the causes of pulmonary stenosis?

A
  1. Congenital - Noonans and Turners
  2. carcinoid
  3. Rheum fever
48
Q

what are the symptoms of pulmonary stenosis?

A

RHF - ascites, raised JVP, peripheral oedema, dyspnoea, tiredness

49
Q

what murmur is heard in pulmonary stenosis?

A

Ejection systolic heard best on inspiration

50
Q

what are the CXR and ECG changes seen in pulmonary stenosis?

A

CXR = Dilated pulmonary artery

ECG = p pulmonare, Right axis deviation

51
Q

what is the difference between valvuloplasty, valvulectomy and valve replacement ?

A

valvulectomy = shaving/remodelling of valve

valvuloplasty = stenting the valve

valve replacement = insertion of mechanical heart valve

52
Q

what are the complications of valve replacement ?

A 
mnemonic = POSH
P = peri-valvular leak - failed
O = obstruction / thrombus of valve
S = sub-acute infective endocarditis
H = haemolysis due to turbulent flow

other complications of surgery: bleeding, stroke

53
Q

What are the complications of TAVI

A

AVN damage
bleeding
Stroke

54
Q

What is treatment for tricuspid regurgitation and tricuspid stenosis?

A

Treat cause, give diuretics

surgery if severe

IPE revision CARDIOLOGY (9 decks)

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