Heart sounds, valvular disease + murmurs Flashcards
what causes the S1 ‘LUB’ sound and when in the cardiac cycle is it heard?
-S1 is caused by the mitral & tricuspid valves shutting
-Heard at the beginning of ventricular systole (shut to stop letting blood enter atria when ventricles contract)
What causes S2 ‘DUB’ sounds and when in the cardiac cycle is it heard?
-Caused by the aortic + pulmonary valves shutting
-Heard at the beginning of ventricular diastole (shut to stop letting blood enter the ventricles from arteries as the ventricles relax)
When is S3 heard?
-Mid ventricular diastole (after S1/ LUB + S2/DUB)
What causes S3?
-S3 is physiological + normal in children/ young adults
-In adults it implies the ventricles are stiff or overloaded, meaning that they cannot stretch easily to accomodate for the incoming blood causing the ventricles to vibrate
Examples of diseases causing volume overload:
-Mitral regurgitation
-HF
Examples of diseases causing stiff ventricles:
-Left ventricular hypertrophy, hypertension + ischaemic heart disease
Is the splitting of S2 sinister?
-Sinister if it is a fixed splitting
-Physiologically normal if during inspiration
(increased venous return to RA + RV during inspiration, this extra blood causes a delay in pulmonary valve closure, splitting S2)
what diseases may present with a fixed splitting of S2?
-Atrial septal defect
-Pulmonary hypertension
-Pulmonary emboli
-Pulmonary stenosis
When is S4 heard?
Late diastolic
-before S1 (LUB) + S2 (DUB)
Is S4 pathological?
S4 IS ALMOST ALWAYS PATHOLOGICAL!!
What causes S4?
-Atrial contraction causing a rapid flow into a less compliant (stiff) ventricle
-Aortic stenosis
-Left ventricular hypertrophy
Give some characteristics of an innocent murmur + what causes it?
innocent murmur is a systolic flow murmur in the right ventricular outflow tract
-mid Systolic (Systolic= Saint= innocent)
-Soft soft + innocent :)
-Localised to one auscultatory area (PA)
-no radiation/ cardiac abnormalities
- Loudest during hyperdynamic state (states of increase CO)
Describe grades I- VI on the Levine scale (scale used to grade intensity of murmurs)
I - Very faint. Can be heard by an expert in optimum conditions.
II- Heard by a non expert in optimum conditions.
III- Easily audible, No thrill.
IV- Loud murmur, with thrill.
V- Very loud, can be heard over a wide area with thrill.
VI- Extremely loud, can be heard without a stethoscope.
*once any of the grading has a V- there is thrill present :)
What type of valve disease causes an ejection systolic crescendo- decrescendo murmur?
-Aortic stenosis
-Pulmonary stenosis
What type of valve disease causes a pansystolic murmur?
-Mitral regurgitation
-Tricuspid regurgitation
What type of valve disease created an early diastolic decrescendo murmur?
-Aortic regurgitation
-Pulmonary regurgitation
What type of valve disease created a mid/late diastolic murmur?
-Mitral stenosis
-Tricuspid stenosis
*early in diastole the ventricle is relaxed + filling to begin with due to gravity, mid way through atria contracts causing murmurrr
Causes of aortic regurgitation?
Due to valvular disease or aortic root disease
Valvular disease:
-rheumatic fever
-old age + degenerative AV disease
-Biscupid aortic valve
-Infective endocarditis
Aortic root disease:
-Aortic dissection
-Collagen vascular disorders (marfans, SLE, ehlers danlos or turner syndrome)
-Spondylothrapies (reactive arthritis + ankylosing spondylitis)
Describe the murmur of aortic regurgitation, what part of stethoscope is best to listen to it + where can it be heard?
-Early diastolic decrescendo murmur
-Heard best at the 2nd ICS right sternal border
-It is high pitched + so use diaphragm (babies scream using their diaphragm + its high pitched)
In severe cases may hear an Austin Flint murmur
Describe what an austin flint murmur is + what is sounds like?
A murmur heard in in cases of severe aortic regurgitation- caused by the regurgitated blood from aortic valve mixing with blood from LA during atrial contraction
Sounds like:
low pitch rumbling
mid- diastolic murmur
heard best at apex.
what are some signs of aortic regurgitation?
-Wide pulse pressure
-Collapsing pulse or Waterhammer pulse (forcefully appearing + rapidly disappearing)
-Displaced hyperdynamic apex beat
-if been going on for a while untreated may notice the patient has develop HF
Medical treatment of acute aortic regurgitation?
Acute= vasodilators + inotropes (is only short term therapy)
Medical treatment of chronic severe AR with HF?
ACEI
Medical treatment of AR with Marfans?
BB (as it may slow aortic dilation)
Who with aortic regurgitation is indicated for surgery?
Symptomatic patients or patients with LVEF <55%
What are the options for surgery in aortic regurgitation?
First line (low or intermediate surgical risk patients)= SURGICAL AORTIC VALVE REPLACEMENT
High risk for surgery e.g. old ppl or ppl that can’t tolerate GA= Trans catheter valve replacement (TAVI)
what are the options for valve prosthesis + what are the pros and cons to each
Biological prosthesis (pig, cow, human):
-less likely to cause blood clots (no need for anticoag)
-but wears faster + may need to be replaced
Mechanical prosthesis (metal or plastic):
-More likely to cause blood clots (metal valve need WARFARIN)
-Lasts a lot longer + less likely to need replaced
what is the most common valvular disease?
Aortic stenosis
Causes of aortic stenosis?
-Elderly: Age-related calcified degenerative (MOST COMMON)
-Young: Congenital bicuspid aortic valve (aortic valve is normally composed of 3 cusps)
-Rheumatic Heart disease (rare but can occur in developing countries)
symptoms of aortic stenosis?
Typically no symptoms until it becomes severe
Symptoms are typically aggravated by exertion:
* SOB on exertion
* Dizziness
* Syncope
AS predisposes angina so may have angina too
Signs of aortic stenosis?
-Reduced or absent S2 too sclerosed to slam shut
-Slow rising pulse
-Narrow pulse pressure (small difference between systolic and diastolic)
-Ejection click would suggest congenital bicuspid (castanets)
What does an aortic stenosis murmur sounds + where is best hear?
- Loudest on expiration or when patient is sitting forwards
- Ejection early systolic Heard after S1 but before S2
- Heard best at the 2nd ICS right sternal border aorTICK= RIGHT
- Radiates to the carotids
- High pitched
-Crescendo-decrescendo murmur
Treatment for aortic stenosis?
SURGERY
First line (low or intermediate surgical risk) = Surgical aortic valve replacement (SAVR)
High surgical risk e.g. older patients or people who fail under general anaesthetic= Trans catheter aortic valve replacement (TAVI)
Bridging or palliative care= Balloon aortic valvotomy occasionally used (BAV)
which valvular disease is part of the tetralogy of fallot + can you name all 4 pathologies in this?
- Pulmonary stenosis
- Ventricular septal defect
- Overriding aorta
- Right ventricular hypertrophy
Causes of pulmonary stenosi?
-Rheumatic fever
-Congenital: Down syndrome, DiGeorge syndrome, Alagille syndrome, Turners, Noonan’s + Willams syndrome
Signs of pulmonary stenosis?
-Raised JVP with giant A waves
-Peripheral oedema
-Ascites
What does the murmur in pulmonary stenosis sound like + where is it best heard?
- Ejection systolic heard after S1 but before S2
- 2nd ICS left sternal border
- Loudest during inspiration due to increased venous return to RA & RV
- Radiates to left shoulder/ left infra clavicular
-Widely split 2nd HS
treatment of pulmonary stenosis?
asymptomatic= monitor
symptomatic or high RV pressure= balloon pulmonary valvuloplasty
causes of mitral stenosis?
-Rheumatic Fever (MOST COMMON)
-Infective endocarditis
-Calcification related to age
-Congenital e.g. Lutembacher’s syndrome (rare heart condition that combines ASD and MS)
symptoms of mitral stenosis?
-Dyspnoea (SOB)
-Fatigue
-AF (Mitral stenosis causes the pressure in the LA to remain elevated + so atria enlarges -> AF)
Signs of mitral stenosis?
-Tapping apex beat
-Atrial Fibrillation
-Malar flush
signs of infective endocarditis if that is the cause:
-Splinter haemorrhages
-Janeway lesions
-Roth sports (fundoscopy)
-Osler’s nodes
-Splenomegaly
what does the murmur sounds like in mitral stenosis + where is it best heard?
- 5th ICS mid axillary line
- Mid- late diastolic (mid-late way through ventricular diastole the atria contract)
- Low pitched listen with bell
- Rumbling due to low blood flow velocity
- Loud S1
*Heard loudest at apex on expiration when patient lies on their left side
treatment for severe mitral stenosis?
TRANSCATHETER VALVOTOMY/ BALLOON VALVUPLASTY (opening the valve):
-If transcath valvotomy unsuitable offer mitral valve replacement
causes of mitral valve regurgitation?
Can be due to a primary valve disorder or secondary to left ventricular dysfunction
PRIMARY VALVE DISORDER:
-Infective endocarditis
-MI causing valve prolapse
-Rheumatic fever
SECONDARY TO LVD
-Cardiomyopathy
-Post- MI
what does mitral regurgitation murmur sounds like + where is it best heard?
-5th ICS left midclavicular line
-Pansystolic occurs throughout ventricle systole (after S1 before S2)
- High pitched whistling
-Radiates to left axilla
What are some signs of mitral regurgitation?
- Displaced apex beat
- Sometimes S3
- Signs of HF + pulmonary oedema
treatment of mitral regurgitation?
MEDICAL THERAPY:
* Diuretics
* ACEI e.g. ramipril (if heart failure develops)
SURGERY:
* Valve repair or replacement (by median sternotomy or minimally invasive surgery)
* MitraClip if can’t tolerate open heart surgery
ACUTE (with rapid pulmonary oedema)- emergency valve repair
