Heart Sounds + murmurs

Question 1

how many cusps does the tricuspid valve have and what are they called?

Answer 1

3 cusps:

• anterior
• posterior
• septal

Question 2

how many cusps does the mitral valve have and what are they called?

Answer 2

2 cusps:

• anterior
• posterior

Question 3

what causes the first heart sound?

Answer 3

(S1) is caused by the closure of the mitral and tricuspid valves

Question 4

what causes the second heart sound?

Answer 4

(S2) is caused by the closure of the aortic and pulmonary valves

Question 5

how many cusps do the pulmonary and aortic valves have?

Answer 5

three cusps:

aortic - left, right and posterior
pulmonary - left, right and anterior

Question 6

what is the cause of S2 splitting?

Answer 6

this is sue to inspiration - as the intra-abdominal pressure to decrease as the volume of the chest increases therefore the amount of blood returning to the heart increases - the increases RV volume increases the RV ejection time, meaning the pulmonary valve closes slightly later - meaning that splitting is heard

Question 7

where is (S2) splitting heard most clearly?

Answer 7

best heard in the pulmonary valve area - left sternal edge, 2nd intercostal space

Question 8

when can you tell if a splitting second heart sound is pathological or not?

Answer 8

if the splitting occurs on inspiration then it is physiological but if not it is pathological

Question 9

when can a third heart sound be heard?

Answer 9

(S3) is an diastolic sound heard shortly before S1

Question 10

why does (S3) occur?

Answer 10

it is due to the acceleration and deceleration of blood that occurs during the passive filling of the ventricles - best heard of the apex beat

Question 11

is (S3) pathological?

Answer 11

in younger patients it can be physiological

but in older patients is t most likely due to LV dysfunction - therefore arrange an echo

Question 12

when can a fourth heart sound be heard?

Answer 12

late diastolic sound heart just before S1 - best heard at the apex beat

Question 13

what is the cause of the fourth heart sound?

Answer 13

the fourth heart sound is due to atrial contraction causing rapid blood flow into a stiff ventricle - therefore caused by decreased left ventricle compliance

Question 14

what are possible specific causes for a stiff ventricle?

Answer 14

examples include, myocardial ischaemia, hypertension and aortic stenosis

Question 15

what murmurs coincide with the carotid pulse and why?

Answer 15

systemic murmurs, because the carotid artery is so close to the heart there isn’t really a time delay between the heart contracting and the carotid artery being filled with blood

Question 16

systemic murmurs?

Answer 16

Mitral regurgitation and Aortic stenosis - notch of which radiate

Question 17

diastolic murmurs?

Answer 17

mitral stenosis, and aortic regurgitation

Question 18

“displaced apex beat”

Answer 18

regurgitation causes an displaced apex beat, stenosis does not

Question 19

“constant machinery murmur”

Answer 19

patent ductus arteriosus

Question 20

causes of mitral stenosis?

Answer 20

prosthetic valve or rheumatic cause

Question 21

signs of mitral stenosis?

Answer 21

malar flush 
low volume pulse
AF common
loud (S1)
rumbling diastolic murmur

Question 22

diagnosis and complications of mitral stenosis?

Answer 22

echocardiogram to diagnose,

complications include:
hypertension, pressure a hypertrophic left atrium on surrounding tissues (dysphasia, hoarseness as compressing laryngeal nerve), emboli

Question 23

management of MS?

Answer 23

diuretics - they increase the preload and venous pressure, beat blockers, digoxin, warfarin

valve replacement surgery, or Valvuloplasty in competent native valve

Question 24

Causes of MR?

Answer 24

Rheumatic heart disease
endocarditis
ischaeia/rupture of papillary muscle
functional due to LV hypertrophy

Question 25

signs of MR?

Answer 25

displaced apex beat

pan systolic murmur - minimal at the apex, radiating to the axilla

Question 26

diagnosis of MR?

Answer 26

echocardiogram, cardiomegaly on CXR, doppler, cardiac cauterisation is diagnostic

Question 27

Management of MR?

Answer 27

diuretics, ACE inhibitors, digoxin, warfarin

surgery (valve replacement/repair)

Question 28

causes of Aortic stenosis?

Answer 28

senile calcification (age related)
congenital (bicuspid valve)
rheumatic disease

Question 29

signs of AS?

Answer 29

low volume, slow rising pulse
forceful apex beat
ejection systolic murmur (maximal in aortic area, radiating to the carotids)

Question 30

diagnosis and management of AS?

Answer 30

echocardiogram, CXR may show LV hypertrophy

valve replacement

Question 31

Causes of aortic regurgitation?

Answer 31

endocarditis, rheumatic heart disease, marfan’s syndrome (genetic condition affecting the bodies connective tissue), acute aortic dissection

Question 32

signs of AR?

Answer 32

high volume, collapsing pulse, displaces apex beat, early diastolic murmur at lower sternal edge

Question 33

diagnosis of AR?

Answer 33

echocardiogram,

CXR: cardiomegaly, pulmonary oedema, dilated defending aorta

Question 34

management of AR?

Answer 34

ACE inhibitors, diuretics (to lower systolic hypertension)

valve replacement before significant LV dysfunction