heart sounds and murmurs Flashcards by Sara Assadi

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

S1 (Lub) = mitral and tricuspid valve closure

S2 (Dub) = Aortic and pulmonary valve closure

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why is S2 often split?

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

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what can a quiet S1 or S2 indicate?

Pericardial effusion and Tamponade

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what causes the 3rd heart sound?

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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what is 3rd heart sound a sign of?

**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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what causes the 4th heart sound?

Atria trying to contract against non-compliant ventricles

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what is the 4th heart sound a sign of?

** always pathological

HF - hypertrophy (diastolic)

Cardiomyopathy - Hypertropic

Post-MI

HTN - hypertrophy

aortic stenosis

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what causes exaggerated splitting of S2 - pathological splitting?

Early closure of aortic = mitral regurg, VSD

Late closure of pulmonary = pulmonary stenosis, ASD

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what can cause splitting of S2 to widen on expiration?

Aortic stenosis or PDA

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state the different systolic and diastolic murmurs

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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how are systolic murmurs graded?

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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what are the causes of mitral stenosis

Calcification with Age
Rheumatic Fever
Congenital

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what Ix could you do for someone with a murmur?

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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what ECG changes are seen in mitral stenosis?

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

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list the signs and symptoms of mitral stenosis

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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how can we manage mitral stenosis

mild - diuretics + anticoagulants + AF management

moderate = Valvulopasty (stent) and valvectomy (shaving)

severe = Valve replacement

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what are the CXR changes in mitral stenosis?

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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what are the indications of severe mitral stenosis

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

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what are the causes of mitral regurgitation

Infective endocarditis
Rheumatic fever
Cardiomyopathy- dilated
Barlow’s syndrome
LV dilation - pulls apart mitral valves post MI
Papillary muscle rupture - post-MI

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what is barlows syndrome? complications of this

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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what ecg changes are seen in mitral regurgitation

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

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how is mitral regurgitation managed?

begin with = diuretics, anticoagulants and manage AF

more severe = valve replacement

what are the signs and symptoms of mitral regurgitation?

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

what indicates severe mitral regurgitation?

larger the LV
decompensated LV failure
AF

what CXR changes are seen in mitral regurgitation

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

what are the causes of aortic stenosis

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

what are the ECG changes seen in aortic stenosis

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

how is aortic stenosis managed?

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

what is contraindicated in aortic stenosis?

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

what is the symptomatic triad seen in aortic stenosis?

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

what are the signs of aortic stenosis?

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

what are the indications for severe aortic stenosis?

S4 heart sound ECHO: - pressure gradient >40mmHg - jet velocity >4m/s - valve area <1cm2 Decompensated left heart failure narrow pulse pressure

what are the CXR signs seen in aortic stenosis

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

what are the complications of aortic stenosis?

Death Heart failure MI

what are possible differentials of aortic stenosis ?

Aortic sclerosis - thickening but no stenosis (get murmur but no change in pulse or radiation to carotids) HOCM: - angina and ejection systolic murmur

what are the causes of aortic regurgitation?

``` mnemonic REAM R = rheumatic fever, RA E = endocarditis A = AS, aortic dissection M = marfans ``` Others - bicuspid aortic valve, ehlers danlos, tertiary syphillis

what are the signs of aortic regurgitation

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

what are the symptoms of aortic regurgitation

symptoms of HF = PND, orthopnoea, fatigue exertional dyspnoea syncope, angina palpitations / arrhythmias (esp AF)

what is the management of aortic regurgitation ?

ACEi and Ca blockers to reduce strain valve replacement in severe disease ECHO every 6-12 months

what indicates severe Aortic regurgitation?

``` S3 heart sound long murmur Wide pulse pressure and collapsing Austin flint murmur decompensated LVF ```

how is a collapsing pulse assessed?

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

what are the CXR changes in aortic regurgitation?

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

what are the causes of tricuspid regurgitation

1. IE 2. RF 3. RA dilation 4. Congenital

what are the signs and symptoms of tricuspid regurgitation

Mid systolic murmur Signs of RH failure - ascites, raised JVP, peripheral oedema Hepatic pain on exertion pulsatile hepatomegaly RV heave

what are the causes of tricuspid stenosis

1. IE 2. congenital 3. RF

what murmur is heard in tricuspid stenosis

Early-diastolic loudest on inspiration

what are the causes of pulmonary stenosis?

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

what are the symptoms of pulmonary stenosis?

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

what murmur is heard in pulmonary stenosis?

Ejection systolic heard best on inspiration

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

CXR = Dilated pulmonary artery ECG = p pulmonare, Right axis deviation

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

valvulectomy = shaving/remodelling of valve valvuloplasty = stenting the valve valve replacement = insertion of mechanical heart valve

what are the complications of valve replacement ?

``` 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

What are the complications of TAVI

AVN damage bleeding Stroke

What is treatment for tricuspid regurgitation and tricuspid stenosis?

Treat cause, give diuretics | surgery if severe