Heart Sounds and Valvular Disease

Question 1

What causes the first heart sound?

Answer 1

Beginning of systole - closure of the mitral and tricuspid valves

Question 2

What causes the second heart sound?

Answer 2

Beginning of diastole - closure of aortic and pulmonary valves

Question 3

What do systolic murmurs coincide with?

Answer 3

Carotid pulse

Question 4

What do diastolic murmurs not coincide with?

Answer 4

Carotid pulse

Question 5

What is physiological splitting of the 2nd heart sound caused by?

Answer 5

• inspiration causes a drop in interthoracic pressure
• this results in increased venous return to the right side of the heart
• right ventricular ejection time increased
• hence, pulmonary component of 2nd heart sound may be delayed

Question 6

What causes a third heart sound?

Answer 6

Early diastolic low frequency filling sound immediately after the 2nd sound
-heard best at the apex

Question 7

When is a third heart sound normal?

Answer 7

child or young adult with no cardiac disease

Question 8

When is a third heart sound not normal (pathological)?

Answer 8

older patient with suspected or known cardiac disease

Question 9

What causes a fourth heart sound?

Answer 9

late diastolic low frequency filling sound before the first heart sound

Question 10

What is a fourth heart sound due to?

Answer 10

atrial contraction causing rapid blood flow into stiff ventricles

Question 11

What diseases can cause a fourth heart sound?

Answer 11

aortic stenosis
hypertension
myocardial ischaemia

Question 12

What is the third heart sound due to?

Answer 12

acceleration and deceleration of blood during early passive filling of the ventricle

Question 13

What causes an innnocent murmur?

Answer 13

Turbulent flow in the right ventricular outflow tract

Question 14

What are the characteristics of an innocent murmur?

Answer 14

• localised to one auscultatory area (normally pulmonary)
• no other cardiac abnormalities
• soft mid systolic

Question 15

Name the two types of systolic murmurs?

Answer 15

Pansystolic – mitral regurgitation, same loudness between the 1st and 2nd heart sound
Ejection systolic – aortic stenosis, crescendo between the 1st and 2nd sound

Question 16

Name the two types of diastolic murmurs?

Answer 16

Early diastolic – aortic regurgitation, early crescendo after 2nd sound
Mid diastolic – mitral stenosis, heard just before the 1st sound

Question 17

What type of murmur is mitral stenosis?

Answer 17

diastolic

Question 18

What type of murmur is mitral regurgitation?

Answer 18

systolic

Question 19

What type of murmur is aortic stenosis?

Answer 19

systolic

Question 20

What type of murmur is aortic regurgitation?

Answer 20

diastolic

Question 21

At what murmur grade can you palpate a thrill?

Answer 21

grade 4

Question 22

Name some causes of aortic stenosis?

Answer 22

Degenerative (age related)
Congenital e.g. bicuspid valve (instead of having 3 valve leaflets they have 2)
Rheumatic fever

Question 23

Name some symptoms of aortic stenosis?

Answer 23

Breathlessness
Chest pain – mimics angina chest pain
Dizziness/syncope

Question 24

Describe the treatment of aortic stenosis?

Answer 24

Conventional valve replacement - mechanical or bioprosthetic
Trans catheter aortic valve replacement (TAVI)
Balloon Aortic valvotomy (BAV)

Question 25

What are the clinical signs of aortic stenosis?

Answer 25

Low volume pulse Forceful displaced apex – heart is pumping against big resistance Ejection systolic murmur that can radiate to the carotids

Question 26

What are the causes of mitral regurgitation?

Answer 26

``` Leaflets - Prolapse - Rheumatic - Myxomatous (floppy) - Endocarditis Chordae rupture (degenerative) - Prolapse/flail leaflet Papillary muscles rupture - Ischaemic Annular dilatation - Functional ```

Question 27

What are the symptoms of mitral regurgitation?

Answer 27

Breathlessness Peripheral oedema Fatigue

Question 28

What are the signs of mitral regurgitation?

Answer 28

Displaced apex Pansystolic murmur – Axilla Cardiomegaly on a CXR

Question 29

What is the treatment of mitral regurgitation?

Answer 29

``` Medication - Diuretics and heart failure (ACE inhibitors) Surgical - Repair – prolapse - Replacement - degenerative Percutaneous - Clips in infancy ```

Question 30

What is the cause of mitral stenosis?

Answer 30

Rheumatic fever | Rare: congenital

Question 31

What are the symptoms of mitral stenosis?

Answer 31

Breathlessness Fatigue Palpitations (AF)

Question 32

What are the signs of mitral stenosis?

Answer 32

Malar flush – co2 retention Tapping apex beat Mid diastolic rumbling diastolic murmur localised to apex

Question 33

What is the treatment of mitral stenosis?

Answer 33

``` Medication - Diuretics and treat AF Surgery - Valve replacement - Balloon Valvuloplasty ```

Question 34

What are the causes of aortic regurgitation?

Answer 34

``` Leaflets - Endocarditis - Connective tissue diseases - Rheumatic Annulus - Marfans - Aortic dissection ```

Question 35

What is the symptom of aortic regurgitation?

Answer 35

Breathlessness

Question 36

What are the signs of aortic regurgitation?

Answer 36

Collapsing pulse Wide pulse pressure Displaced apex Early diastolic murmur left sternal edge

Question 37

What is the treatment of aortic regurgitation?

Answer 37

``` Medication - ACE inhibitors Surgery - Symptoms and LV dilatation - Valve replacement ```