Heart sounds & murmurs Flashcards
What causes an S3?
- Blood filling a dilated, failing heart
- Best heard @ apex with bell
- Sounds like “montreal”
What causes an S4?
- Blood filling a stiff ventricle
- Best heard @ apex with bell
- Sounds like “Toronto”
What causes an opening snap?
- A stenonic MITRAL or TRICUSPID valve opening during diastole
- High pitched, does not vary with respiration
- Mitral best heard around apex
What causes a crescendo-decrescendo systolic murmur?
- Aortic stenosis (radiates to right carotid)
2. Pulmonary stenosis (may change with respiration)
What causes a pansystolic murmur?
- Mitral regurgitation
- Tricuspid regurgitation
- Ventricular septal defect
What causes a late systolic murmur?
- Mitral valve prolapse (ejection click)
Aortic Stenosis
- Right upper sternal border, with radiation to carotids
- Crescendo-decrescendo (later=more severe)
- Mid-harsh pitch
- Associated with pulsus parvus et tardus, apical-carotid delay, sustained apex, soft S2, S4
- Caused by degeneration, bicuspid valve, rheumatic
Hypertrophic obstructive cardiomyopathy
- Left sternal border to apex
- crescendo-decrescendo, dynamic: increases in volume wtih Valsalva, squat to stand
- Mid-harsh pitch
- Spike and dome pulse, palpable S4, MR murmuer
- Familial disease
Flow murmur
- Left sternal border
- crescendo-decrescendo (early peak)
- Mid-high
- No associated findings
Pulmonic stenosis
- Left upper sternal border
- crescendo-decrescendo
- Mid-high
- Right ventricular heave, right S4
- Typically congenital
Mitral regurgitation
- Apex, radiates to axilla
- Pansystolic
- Mid pitch
- Low volume pulse, dilated left ventricle/atrium, S3
- Degenerative, dilated left ventricle, endocarditis, papillary muscle rupture
Mitral valve prolapse
- Apex, radiates to axilla
- Late systolic murmur + ejection click, dynamic (increases with Valsalva, squat to stand)
- Associated with systolic click, low volume pulse, dilated LA/LV, S3
Tricuspid regurgitation
- Left lower sternal border
- Pansystolic murmur
- Mid pitch
- Associated with right ventricular heave, palpable P2, right sided S3/4
- Caused by dilated RV, endocarditis, pulmonary HTN
VSD
- Left sternal border
- Pansystolic murmur, CONTINUES PAST S2
- Mid-harsh
- Associated with palpable P2, possible low volume pulse
- Causes= congenital, post MI, traumatic
Aortic regurgitation
- Left upper sternal border, radiates to apex
- Decrescendo
- High pitch
- Narrow pulse pressure, diffuse apex, S3, Water Hammer Pulse etc.
- Causes= degeneration, bicuspid valve, aortic dilation, rheumatic
Pulmonary Regurgitation
- Left upper sternal border, radiating to lower border
- Decrescendo (may vary with respiration)
- High pitch
- Palpable P2, RV heave, R S3/S4
- Caused by pulmonary HTN, congenital
Mitral stenosis
- Apex
- Mid diastolic rumble (increases right before S1)
- Low pitch
- Opening snap (sail gybe), tapping apex, noS3/S4
- RHEUMATIC!!
Tricuspid stenosis
- Left lower sternal border
- Mid diastolic rumble with pre-systolic increase
- Low pitch
- Elevated JVP, slow y descent
- Congenital or carcinoid
Why does the second heart sound split?
- Splits because of change in pressure in the pulmonic system caused by inspiration.
- This makes P2 later compared to A2
- May also be PARADOXICALLY split (A2 first) in aortic stenosis
What causes a prominent a wave on JVP?
- Tricuspid stenosis, pulmonary hypertension, RVH
2. Increased resistance to forward flow RA-RV
What causes a prominent v wave on JVP?
- Back flow from RV into RA during systole (“CV” wave)
2. Tricuspid regurgitation
What causes a canon a wave on JVP?
- Simultaneous RA/ RV contraction (RA contracts against a closed valve.
- 3rd degree heart block
What causes a prominent/steep y wave on JVP?
- Constrictive pericarditis
2. Blood quickly exits RA, fills RV. Sharp change when RV is full as no capacity to stretch.
What causes an absent a wave on JVP?
- Atrial fibrillation
2. No atrial contraction- lose the increase in pressure that results from atrial kick
What causes a pressure gradient between the left atrium and ventricle?
- Mitral stenosis
What causes a large LA v wave?
- Mitral regurgitation- blood is flowing back from LV-LA during systole
What causes a pressure gradient between the left ventricle and aorta?
- Aortic stenosis
2. Increased resistance to forward flow!
What causes a rapidly falling aortic pressure (on Wiggers)
- Aortic regurgitation
2. Pressure falls quickly during diastole
