Murmur Power review Flashcards
Tricuspid regurgitation
holosystolic murmur which is best heard at the left lower sternal border (4th interspace) with radiation to the left upper sternal border. Murmur will increase with inspiration due to increased right-sided venous return during inspiration
Tricuspid valve location
Between the R Atria and R ventricle
Aortic Stenosis
Harsh crescendo-decrescendo mid-systolic ejection murmur.
**Very commonly radiates to R neck. If you don’t hear radiation- make a 2nd guess on diagnosis
Aortic stenosis is best heard
2nd R interspace. Pt is sitting and leaning forward
Aortic valve location
Between the L ventricle leading to Aortic arch
S1 sound (beginning of systole) What valves close
Mitral and tricuspid valves close
S2 sound (end of systole) What valves close
aortic and pulmonary valves closing
IMPT Avoid what pharmacologic with outflow obstruction problems such as Aortic Stenosis
Systemic vasodilators such as Nitrates are not recommended (risk of SEVERE hypotension)
Aortic stenosis pt presentation
- middle aged 25% are 65 years of age
- external dyspnea
- syncope
- CHF
- Atherosclerosis
Aortic stenosis
Most common valvular heart disease in the US
Treatment for angina for aortic stenosis pts
- Beta blockers
2. Calcium channel blockers
Aortic valve is typically what kind of valve
Tricuspid valve
Treatment options for aortic stenosis
- Prosthetic valve (lasts longer but have to be on lifelong anticoagulation)
- Pericardial and porcine valves- do not require anticoagulation but have shorter life span.
- Ross procedure- replacement of aortic valve with own pulmonary valve and then replace pulmonary valve.
- Balloon valvuloplasty - not effective long term
Mitral valve regurgitation murmur sound
pan systolic (holo systolic) blowing murmur radiating to the axilla.
Mitral valve regurgitation is best heard
L 5th interspace at the Apex. Left lateral decubitus may amplify murmur.
When is Mitral valve regurgitation decreased and increased
- Decreased with valsalva or standing
2. Increased with hand grip or squatting
May be heard in Mitral regurgitation
- Low S3 (indicating heart failure)
Mitral valve patient characteristics
Thin Female with mitral valve prolopse.
Mitral valve prolapse is the most common cause of
Mitral regurgitation
PE findings mitral valve regurgitation
- Thin Female
- exertional dyspnea
- orthopnea
- Paroxysmal nocturnal dyspnea 2/2 pulmonary congestion
What happens with mitral regurgitation (ventricle visualization)
When the L ventricle contracts, blood leaks back into the L atrium (causing backup into the lungs)
Mitral valve regurgitation how does it affect preload and ejection fraction
- Causes an increase in preload and an increase in ejection fraction (early stages).
- Long term. Enlarged left ventricle and decreased ejection fraction.
- Eventually leads to pulmonary congestion.
Causes of mitral regurgitation
- Congenital
- Degenerative mitral valve disease
- Thin females with mitral valve prolapse
- Rheumatic heart disease
- Trauma to mitral valve
- MI
- Ruptured chordae tendinae (MI or endocarditis most likely)
- Endocarditis (regurge can also put pt at increased risk for endocarditis)
- Cardiomyopathy
Mitral valve prolapse sound
Mid-systolic click
Mitral regurgitation carotid exam
Brisk carotid upstroke
Mitral regurgitation lung ascultation
rales 2/2 pulmonary congestion
Mitral regurgitation EKG findings
- Atrial fibrillation
2. L ventricular hypertrophy
Diagnosis mitral regurgitation
- pansystolic blowing murmur at the Apex L 7th interspace radiating to Axilla
- Echo with doppler shows severity of regurge and bloodflow
- cardiac cath may be used for further assessment
Treatment mitral regurgitation
- Atrial fibrillation- cardioversion, warfarin
- Pulmonary congestion- diuretics, vasodilators
- Surgery - valve repair or valve replacement
Tricuspid regurgitation is this a systolic or diastolic murmur
holo SYSTOLIC murmur, L 4th interspace
Aortic regurgitation (insufficiency) murmur sound
Early diastolic decrescendo in 2nd to 4th Left interspace. Best heard with pt sitting and leaning forward
What helps increase the sound in aortic regurgitation
Isometric exercise will increase systemic vascular resistance and INCREASE the sound of the murmur.
How does aortic regurgitation affect arterial pulse pressure
You will hear a high arterial pulse pressure with a quick drop in pressure during diastole
Findings in labs and studies with aortic regurgitation
CXR: L ventricular hypertrophy
ECG: L ventricular hypertrophy
Echo with doppler is diagnostic
Cardiac cath may also be used
Treatment with aortic regurgitation
- Blood pressure control on decreasing afterload
2. Valve replacement
Aortic regurgitation pathophysiology
Stroke volume and systolic blood pressure are increased. The diastolic blood pressure decreases leading to a wind pulse pressure which eventually leads to myocardial ischemia - LV hypertrophy
What is cardiac preload
The preload is the amount of stretch or pressure left in the left ventricle at the end of diastole—when the heart is the most relaxed. It is also referred to as the left ventricular end-diastolic pressure or LVEDP. The greater the preload, the more pressure is available for the next cardiac contraction.
What is cardiac afterload
The afterload is the amount of vascular resistance that must be overcome by the left ventricle to allow blood to flow out of the heart. It is also referred to as the systemic vascular resistance or SVR. The greater the afterload, the harder the heart has to work to push blood through the systemic vasculature.
What medications reduce afterload?
Low doses will reduce the preload, while high doses will mildly reduce the afterload. Furosemide (Lasix) and other loop diuretics will decrease the preload by decreasing the total blood volume. These drugs do not act on the heart but cause renal diuresis within an hour of intravenous administration. ACE-I (blocks the formation of certain chemicals that act on the body to maintain adequate blood pressure) Using these meds allows the vessels to relax and dialate. Sample ACE-I: enalapril, captopril, lisinopril also reduce afterlaod
Aortic regurgitation pt presenation
Pt’s typically asymptomatic until middle age: exertional dyspnea, orthopnea, angina, PND, palpitations.
Males most common (3:1)
Causes of aortic regurgitation
- Aortic root dilation (80% idopathic)
- Aging
- HTN
- Rheumatic Fever
- Congetial bicuspid aortic valve (normally tricuspid)
- Diseases
a) marfan’s
b) Ehlers Danlos syndrome
c) ankylosing spondylitis
d) systemic lupus
e) syphilis
Acute setting
a) endocarditis
b) aortic dissection
Mitral stenosis murmur sound
Diastolic decrescendo-crescendo murmur with NO Radiation best heard at cardiac apex L 5th (midclavicular 4th or 5th intercostal space) Listen at the end of Expiration in the Left Lateral Decubitus position
What exacerbates mitral stenosis murmur
Valsalva or exercise will exacerbate the murmur
You may hear the following sound following S2 in mitral stenosis
Opening snap
Causes of mitral stenosis
Rheumatic heart disease
Mitral stenosis pt
- External dyspnea
- orthopnea
- PND 2/2/ pulmonary congestion
- Rales 2/2 pulmonary congestion
- Atrial fibrillation
Mitral stenosis treatment
- Treat Afib (cardioversion, warfarin)
- Pulmonary congestion (diuretics, vasodilators)
- Surgery (percutaneous balloon valuloplasty vs valve replacement)
Diagnostic for mitral stenosis
- Echo with Doppler is diagnostic.
2. Cardiac cath may help to assess overall health of heart (not diagnostic)
Pulmonary regurgitation murmur sound
Early diastolic decrescendo murmur. It is heard best in the L sternal border. +/- radiation to R sternal border
Pulmonary regurgitation is best heard in what pt position
Pt sitting and holding breath at end of expiration (blow out and hold breath)
Causes of pulmonary regurgitation
- Congenital
- Pulmonary hypertension (increased backflow problems)
- endocarditis
- Rheumatic heart disese
- Plaques
- Iatrogenic
Labs in pulmonary regurgitation
- ECG may show R ventricular hypertrophy
- Echo with doppler will show extend of regurgitation
- Cardiac cath may be used to gain info
Treatment of pulmonary regurgitation
- Typically well tolerated and does not require intervention
- Valve may be replaced or repaired
- Address underlying cause of pulmonary regurgitation. It is typically a symptom of a larger problem
Murmur in Tricuspid Stenosis
Diastolic decrescendo murmur best heard at left lower sternal border
Tricuspid Stenosis and signs of heart failure
Signs of R heart failure will be present
Pulmonary regurgitation and valvular pathology
It is the lease common valvular pathology
Pulmonary stenosis murmur description
It produces a systolic crescendo-decrescendo ejection murmur WITHOUT radiation. It is best heard in the L sternal border in the 2nd - 4th intercoastal spaces
Other characteristic sounds heard in pulmonary stenosis
Wide splitting of S2 (it takes longer to empty the RV.
Pulmonary stenosis is best heard in what pt position
Pt is leaning foward. Valsalva ENHANCES murmur
S2 represents
closing of aortic and pulmonary valves
Labs diagnostic pulmonary stenosis
Echo
Treatment pulmonary stenosis
- Follow with Echo
- Valvotomy
- Valve repair
- Valve replacement
Pulmonary stenosis pt presentation
- Most pts are asymptomatic
- Cyonosis
- Dyspnea
- Dizziness
Hypertrophic Obstructive Cardiomyopathy murmur sound
Produces systolic crescendo-decrescendo murmur best heard at the left lower sternal border
What enhances the murmur in hypertrophic obstructive cardiomyopathy
Valsalva maneuver and changing positions from squatting to standing will increase the intensity of the murmur
