Heart Sounds/ Physiology Flashcards
- Faint, only audible by listening carefully for a period time
Grade 1
- Faint, but easily heard
Grade 2
- Moderately loud, not thrill
Grade 3
- Very loud, thrill palpable
Grade 4
- Extremely loud, heard with edge of stethoscope, thrill present
Grade 5
- Heard without the use of stethoscope, thrill
Grade 6
Ways that increase venous return?
- Inspiration (decreases intrathoracic pressure, increases venous return, increases blood flow across right sided valves)
- Squatting (increases venous return to the heart, increases ventricular filing, increases blood flow across valves
- Amyl Nitrate
Exceptions: hypertrophic cardiomyopathy & Mitrial valve prolapse
which valves are the most important for normal function of the heart? which rarely cause significant clinical problems?
- Mitrial and Aortic valves most important for normal functioning of the heart
- right sided valve problems rarely cause significant clinical problems
which valves are open during systole?
- Aortic and pulmonic valves OPEN
which valves are open during diastole?
Mitrial and Tricuspid OPEN
What decreases stroke volume/delivery to the heart?
-
Valsalva Maneuver (straining increases intrathroacic pressure; which decreases venous return to the heart; which leads to decreased left ventriuclar filling; and decreased blood flow) across valves
* 2. Standing (decreases venous return to heart, decreases left ventricular filling/stroke volume, decreases blood flow across valves)
- pathophys: LV outflow obstruction leads to fixed cardiac out, increased afterload, left ventricular hypertrophy
- EKG: Heightened QRS due to ventricle muscle hypertrophy
- systolic crescendo-decrescendo murmur best heard at the right upper sternal border; radiating to the carotid artery
- sx when severe: dyspnea or syncope with exertion; angina, Myocardial infarction
Aortic stenosis
- early diastolic blowing decrescendo murmur best heard at the left upper sternal border
- high peripheral pressure causes blood flow to flow back over valve
- also leads to ventricular hypertrophy
- when severe intensity of murmur, sound may decline due to heart failure and high diastolic ventricular pressure(soft doesn’t mean better)
Aortic insufficiency/Regurgitation
- most common cause of mitrial regurgitation in the US
- Leaflets of the mitrial valve bulge into the left atrium during systole
- mid-late systolic ejection click best heard at the apex
- sx: most are asymptomatic, but may have autonomic dysfunction(anxiety, atypical chest pain, panic attacks, palpitations)
valsalva/standing= earlier click; squatting, leg raise= delayed click
Mitrial valve prolapse
- systolic murmur
- asymmetric hypertrophy of intraseptal wall of ventricle
- ventricle contracts and casues dynamic stenosis/obstruction of the aortic output
- beta blockers to decrease velocity of contraction and increase residual volume
- EKG: ventricular hypertrophy = heightened
Idiopathic hypertrophic subaortic stenosis
- failure of foramen ovale to completely close
- systolic crescendo-decrescendo ejection murmur best heard at the pulmonic area
- widely fixed, split S2- doesn’t vary with respirations
- most patients asymptomatic or minimal until > 30yrs
Atrial Septal Defect
- Most common type of congenital heart disease in childhood
- due to failure of septum to fuse as a fetus
- high pitched harsh holosystolic murmur best heard at the lower left sternal border
- may get louder as get smaller so can’t always tell severity based on how loud murmur is
- dx: ECHO
Ventricular Septal Defect
- chronic right ventricular overload leads to pulmonary hypertension
- pulmonary hypertension leads to increased right ventricle hypertrophy and increases right ventricle pressure
- as pressure rises- difference between right and left deacreases
- right ventricle pressure can become higher than L ventricle and blood flows R-L
Eisenmonger phenomena
- Prominent S1, opening snap; low pitched mid-diastolic rumbling murmur best heard at the apex.
- between beats atrium pushes blood into ventricle
- increases with expiration
- sx: dyspnea, can have atrial fibrillation, ruddy, flushed cheeks with facial palor, hoarsness
Mitrial Stenosis
- Abnormal regrograde blood flow from the left ventricle into the left atrium, leading to left atrial dilation & increased pulmonary pressure
- blowing holosystolic murmur beast heard at the apex with radiation to the axilla
- EKG: atrium has to work harder, hypertrophies, P wave heightened
- sx: dsypnea most common, atrial fibrillation
- tx: symptom control with afterload reducers (ACE inhibitor, ARB; repair preferred over replacement
Mitrial regurgitation
for systolic murmurs- what is considered forward flow? when do they begin?
aortic stenosis
pulmonic stenosis
(begin shortly after S1, increase to peak and rapidly decrease to finish shortly before S2)
for systolic murmurs- what is considered regurgitant flow? when do they begin?
mitral and tricuspid (begin immediately after S1 and last to or through S2)
These murmurs have a blowing quality, even intensity
considered pansystolic murmur
- S1 usually normal
- S2: A2 decreased or absent. Paradoxical splitting
- ejection sound present if valve not heavily calcified
- S4: when present indicates stenosis
- murmur: systolic, diamond shaped, R-ICS, radiates to carotids, pt sitting up and leaning forward, severity correlates to duration of murmur, not intensity
- thrill palpable at carotids
Aortic valvular stenosis
- S1 normal
- S2 fixed split at pulmonic area
- murmurs: increased bloodflow across PV, soft, systolic ejection murmur heard at 2nd-4th L-ICS
Atrial Septal Defect (ASD)
- S1 normal
- S2: Wide split with large shunt
- S3: frequent
- Murmur: pansystolic (holosystolic), high frequency with even intensity. Loud=small defect. Heard best between apex and LLSB
- may associate with palpable thrill
Ventricular septal defect
common causes of mitral valve regurgitation?
rheumatic heart disease
Post MI
MVP
LV dilation with left heart failure
CHF
- S1: normal or decreased in intensity
- S2: normal or occasional paradoxical split
- S3: present
- murmurs: holosystolic “blowing”, best heard at the apex with radiation to the left axilla. High frequency
- associated findings: systolic thrills
mitral regurgitation
most common systolic murmurs?
aortic stenosis and Mitral regurg
- sustained noises between S2 and S1
- not normal and need further evaluation
- 3 main mechanisms: Aortic or pulmonic valve incompetence, mitral or tricuspid stenosis, increased blood flow across the mitral or tricuspid valve
diastolic murmurs
- S1: Normal
- S2: Normal
- S3: May be present at apex
- mumur: Soft, early diastolic decresencdo, high-pitched, blowing, heard best with diaphragm. pts should lean forward and exhale
- Associated findings: Water hammer pulse, wide pulse pressure, displaced PMI, cardiac hypertrophy on CXR
Aortic regurgitation
- S1: Loud S1
- S2: Loud P2
- Opening snap: early diastolic, high frequency. Follows A2
- murmur: mid-diastolic, low pitched rumbling. Heard best at the apex with bell, pt in Left lateral Decubitus
- associated findings: parasternal lift 2/2 pulmonary HTN and RV hypertrophy. Thrill may be present at mitral area
Mitral stenosis
Split S2 w/ inspiration.. think?
physiologic split S2
reverse split S2… think?
also seen as paradoxical split
Left bundle branch block
Wide split S2…think?
right bundle branch block
fixed split S2…think?
Atrial Septal defect
S3 is usually due to a volume overloaded heart but can be normal in children and young adults. What is considered Volume overloaded states?
Listen to S3 with Bell
- CHF
- Advanced mitral regurgitation
- VSD
- dilated cardiomyopathy
S4 is often due to decrease compliance usually due to ventricular hypertrophy. What is considered pressure overloaded states?
Listen to S4 with bell
- Hypertrophic cardiomyopathy
- Aortic Stenosis
- Hypertension
- ischemic heart disease
