Heart Sounds II & III Lecture Powerpoint Flashcards
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When you hear a murmur, need to order what diagnostic study…
…an echocardiogram
Gradation of heart murmurs and what grade is consistent with pathological heart disease
1 - very faint, may not be heard in all positions
2 - quiet but heard immediately
3 - moderately loud
(anything below here is pathologic for heart dz)
4 - loud with palpable thrill
5 (systolic only) - loud with thrill may be heard when stethoscope is partially off chest
6 (systolic only) - very loud with thrill may be heard with stethoscope completely off chest
Cooing dove murmur is always associated with…
Still’s murmur
Innocent murmurs characteristics (5)
- grad I-III only
- no clicks
- brief duration, never solely diastolic
- echo will be normal
- no associated pathological findings
Still’s murmur
Most common innocent murmur of childhood (2-6 y.o.), grades I-II, due to vibrations of leaflet attachments in kids, midsystolic heard best at left lower sternal border, vibratory like dove cooing, typically worsened with exercise or excitement
Innocent pulmonary systolic murmur
In 8-14 y.o, grades I-III, peaks during mid systole and heard best at left upper sternal border, has no associated symptoms, typically worsened with exercise or excitement
Physiologic peripheral pulmonic stenosis (PPS) murmur
Due to small relative size of pulmonary artery with acute angle often in newborns or premature, lasts 3-6 months otherwise must re-evaluate, graded I-II heard best at left upper sternal border
Venous hum
Most common continuous innocent murmur, due to turbulence of jugular and subclavian venous return where they meet in the superior vena cava, heard best in the infraclavicular region, disappears when supine, with gentle compression of jugular venous return, or turning head to contralateral side (physiologic compression of return)
Aortic stenosis murmur
-heard over aortic area midsystolically often diminishing S2, increases when squatting, associated with ejection click, pulsus parvus et tardus
Pulmonic stenosis murmur
-Infrequent often part of congenital disorder, heard over pulmonic area systolic murmur often causing wide splitting of S2 (during inspiration), radiates to carotids or back, causes JVD and possible cyanosis
Pulmonic stenosis symptoms (4)
Exertional angina, SOB, fatigue, dizziness
Pulmonic stenosis treatment and one complication
Percutaneous balloon angioplasty, can result in regurgitation
VSD 2 sequallae
- RV hypertrophy
- pulmonary hypertension
Infants with VSD
Have failure to thrive because they are fatigued and have to choose between breathing and eating and thus must be prescribed high caloric density formula
VSD murmur
Holosystolic heard best at tricuspid area, causes wide split of S2
VSD treatment options (5)
- If defect is small no treatment needed
- Endocarditis prophylaxis
- Increased caloric need
- Diuretics
- Usually close on own but might need surgical intervention if large
Atrial septal defect (ASD) definition
Congenital disorder caused by spontaneous malformation of the interartrial septum (closure of foramen ovale) from communication between atria resulting in left to right shunt with turbulent blood flow between atria leading to murmur, can be asymptomatic but progresses with age increasing risk of clot formation
Atrial septal defect murmur
Avoid valsalva, auscultated over pulmonic area, fixed split S2 in inspiration and expiration,
Atrial septal defect treatment (1)
Surgical intervention
Mitral regurgitation Causes (7)
- weakness in mitral valve leaflets
- damaged chordae tendinae
- Papillary muscle ischemia
- annular dilation
- infectious endocarditis
- LVH
- rheumatic heart disease
Mitral regurgitation murmur
holosystolic heard at axilla increased with squatting
Most common cause of mitral regurgitation
Mitral valve prolapse
Mitral valve prolapse is a ___ murmur heard at the ___
mid late systolic murmur (mid systolic non-ejection click occurring after carotid upstroke), apex (mitral area)
Carvallo’s sign
A pansystolic murmur that increases in intensity upon inspiration, clinical sign of tricuspid regurgitation*** and used to differentiate it from mitral regurg
Aortic stenosis sound
Early diastolic, heard over aortic area better when leaning forward and decreased with valsalva
Ejection click vs opening snap
Ejection click occurs during systole (sometime following S1) and opening snap occurs during diastole (following S2)
Mid systolic non ejection click
A click heard in the middle to end of systole that indicates mitral valve prolapse
Holding breath and leaning forward allows for better hearing of these 2 murmurs
- aortic regurgitation
- pericardial friction rub
Strain phase of valsalva allows for better hearing of this murmur
-HOCM
Squatting allows for better hearing of these 2 murmurs
- aortic stenosis
- mitral regurg
Left lateral decubitus allows for better hearing of this murmur
-mitral stenosis
Valsalva mech of action
- Increase in intrathoracic pressure from inspiration collapses Vena cavae, decreasing venous return
- Decreased stroke volume of left heart results causing reflex tachycardia
- Upon release increased venous return
- corresponding increased stroke volume from left heart causes brief spike in blood pressure
- reflex bradycardia lowers heart rate back to normal
- blood pressure returns to normal
Narrowing of pulse pressure is associated with this condition
Aortic stenosis
Carcinoid syndrome
Signs and symptoms resulting from growth of carcinoids (slow growing, often nonmalignant tumors) that can cause pulmonary and tricuspid valve thickening an endocardial fibrosis (although its rare), most often causes flushing and diarrhea
Ventricular septal defect (VSD) definition
A left to right shunt due to congenital hole in the intraventricular septum
Mitral regurgitation treatment options (4)
- B blocker
- Diuretics
- vasodilators
- surgical intervention
Mitral valve prolapse mech of action and populations affected
- most often due to inability of chordae tendinae and papillary muscles to tether leaflets and keep valve closed during all of systole
- females aged 20-30 most often, men greater than 50 highest risk of complication
Mitral valve prolapse symptoms (4) and treatment
- mostly asymptomatic
- palpitations
- syncope
- tingling in hands and feet
-surgical repair in extreme cases
Tricuspid regurgitation murmur
Holosystolic heard best at the lower left sternal border, increased intensity during inspiration (carvallo’s sign)
Tricuspid regurgitation treatment (3)
- anticoagulants
- antiarrhythmics
- surgical repair
Mitral stenosis murmur
Diastolic murmur described as opening snap after S2 heard best in the mitral area
Aortic regurgitation murmur
Early diastolic murmur heard best in the aortic area
Aortic regurgitation symptoms (3)
- palpitations
- angina
- left heart failure (can’t lie flat)
Water hammer pulse
Jerky pulse that is full then collapses because of aortic insufficiency
Traube’s sign
Sharp sound over the femoral artery due to collapse of the arteries due to aortic insufficiency
Aortic regurgitation treatment options (3) and one to avoid
- vasodilators, ACEI, nifidepine
- Avoid B blockers
Most casees of mitral valve stenosis are caused by…
….rheumatic fever
Mitral stenosis murmur
Quiet diastolic murmur with opening snap after S2, heard best at apex and left lateral decubitus or axilla
Mitral stenosis symptoms (3)
- undiagnosed for years
- exercise intolerance
- hemoptysis
Mitral facies
Pink or purple patches on cheek due to vasoconstriction because of severe mitral stenosis decreasing perfusion
Mitral stenosis treatment options (4)
- B blockers
- diuretics
- balloon valvuloplasty
- valve replacement
Tricuspid stenosis common causes (3)
- co-occurs with other disease
- rheumatic fever
- congenital disease
Tricuspid stenosis symptoms (3)
- ascites
- hepatomegaly
- peripheral edema
Tricuspid stenosis murmur
opening snap heard best along mid left sternal border augmented by carvallo’s sign
Pulmonic regurgitation
90% of population has it, most common cause of severe is pulmonary hypertension
