Murmurs

Question 1

Aortic Stenosis

Answer 1

CRESCENDO- DECRESCENDO murmur R 2nd intercostal space

• increased murmur when leaning forward (ERBs) and increased venous return (squatting, supine, leg raise)
• pulsus parvus et tardus (weak, delayed carotid pulse)
• Etiology:
  
  • degenerative: calcifications > 70 yo
  • congenital & bicuspid valve <70 yo
• S/sxs: ASH
  
  • angina
  • syncope
  • heart failure
• Dx:
  
  • ECHO = best test
  • ECG = L ventricular Hypertrophy
• Tx: aortic valve replacement = ONLY effective treatment

Question 2

Aortic Regurgitation

Answer 2

Diastolic high-pitched blowing DECRESCENDO murmur along LSB +/- apex

• murmur LOUDER when sitting up and leaning forward
• Etiology:
  
  • acute → MI, aortic dissection, endocarditis
  • chronic → aortic dilation, rheumatic fever, HTN
• Physical Exam:
  
  • Water hammer pulse: swift upstroked and rapid fall of radial pulse accentuated with wrist elevation
  • De-Musset’s Sign: head-bobbing with heart beat
  • Hill’s Sign: popliteal artery systolic pressure > brachial artery by 60 mmHg (most sensitive)
  • Quincke’s Pulses: visible pulsations in the fingernail bed
  • Muller’s Sign: visible systolic pulsations of the uvula
• Dx:
  
  • Echocardiogram → regurgitant jet
  • L ventricular dilation as compensation
• Tx:
  
  • decrease the afterload improves the forward flow (e.g. ACE-I, ARBs, nifedipine, hydralazine)
  • surgery = definitive tx
    *

Question 3

Mitral Stenosis

Answer 3

• Diastolic murmur heard best at the apex
• LOUD S1 (forceful closure of mitral valve) with OPENING SNAP (forceful opening of mitral valve →early diastolic sound followed by a mid-diastolic rumbling murmur.
  
  • → initial rumble during passive filling of ventricle, followed by active rapid filling during atrial “kick”
• Etiology: rheumatic heart disease = most common cause!
• S/sxs: increased L atrial pressure/volume overload → pulm congestion → pulm HTN → CHF
• Dx:
  
  • ECG = L atrial enlargement, A fib, pulmonary HTN (RVH, R axis deviation)
  • ECHO = most useful non-invasive tool
  • Cardiac Cath = most accurate but rarely done
• Tx:
  
  • percutaneous balloon valvuloplasty

Question 4

Mitral Regurgitation

Answer 4

Systolic murmur Blowing Holosystolic murmur heard best at the APEX → murmur radiates to the axilla, can be heard well in the LLD position

• Etiology: Mitral Valve prolapse = most common cause in the US
  
  • rheumatic fever = most common in developing countries
  • MI/ischemia → papillary muscle dysfunction
  • dilated cardiomyopathy → ruptured chordae tendineae
• S/sxs:
  
  • dyspnea = most common, blood backs up into L atrium then lungs
• Dx:
  
  • ECHO = most useful non-invasive test
• Tx: sx control by reducing afterload (ACE-I, ARBs)
  
  • surgery = repair > replacement

Question 5

Mitral Valve Prolapse

Answer 5

Mid-late systolic ejection click best heard at the apex

• → any maneuver that makes the LV smaller (decreases preload) results in an earlier click & longer murmur duration (e.g. valsalva, standing) due to increased prolapse
• MVP = MOST common cause of mitral regurgitation
• Population:
  
  • Most common in young women
• Dx:
  
  • ECHO → posterior bulging leaflets
• Tx:
  
  • MVP is associated with good prognosis → reassurance
  • beta-blockers for pts with autonomic dysfunction
  • mitral valve repair only for severe regurg and CHF

Question 6

Pulmonary Stenosis

Answer 6

harsh mid-systolic crescendo-decrescendo murmur

• murmur increases with inspiration (bigger preload)
• Pathophys:
  
  • Right ventricle encounters more resistance → hypertrophy → less preload→ blood backs up
• epidemiology:
  
  • almost always congenital and in the young
• Tx: balloon valvuloplasty

Question 7

Pulmonary Regurgitation

Answer 7

Diastolic decrescendo murmur best heart at the L upper sternal border

• murmur increases with inspiration and venous return
• Pathophys:
  
  • retrograde blood flow from the pulmonary artery into the Right Ventricle causing R-sided volume overload
• Etiology:
  
  • almost always congenital

Question 8

Tricuspid Stenosis

Answer 8

mid-diastolic rumbling murmur at the lower left sternal border

• blood backs up into the R atrium causing R atrial enlargement which may lead to R-sided heart failure
• Tx:
  
  • decrease R atrial volume overload with diuretics and Na restriction
  • surgery

Question 9

Tricuspid Regurgitation

Answer 9

Holocystolic murmur at 4th ICS left midsternal border

• may radiate to liver
• Pathophys:
  
  • blood flows back into the R atrium
• Etiology:
  
  • functional overload (pulm HTN, RV dilation)
  • dirty needles (staph etc often up on tricuspid valve)
• PE:
  
  • Carvallo’s Sign:
    
    • holosystolic murmur that becomes louder during inspiration
• Tx:
  
  • tx the underlying condition
  • valve replacement

Question 10

S3

Answer 10

Sys-tol-ic Murmur

can be normal in young and athletic hearts

associated with a dilated ventricle (more compliant ventricle)

Question 11

S4

Answer 11

di-a-stol-ic

atrial kick against a stiff wall, associated with hypertrophy or scar

NEVER normal

Question 12

What can accentuate mitral murmurs

Answer 12

Left lateral decubitus position with the bell

Question 13

What can accentuate aortic murmurs

Answer 13

sitting up and leaning forward

Question 14

What does increasing venous return do?

Answer 14

increases intensity of all murmurs EXCEPT hypertrophic cardiomyopathy, mitral valve prolapse

“the MVP Hates Conforming to the rules”

Question 15

Pneumonic to remember which murmurs are diastolic

Answer 15

MS. PRARTS DIED

MS = mitral stenosis

PR = pulmonary regurg

AR = aortic regurg

TS = tricuspid stenosis

DIED = diastolic, everything else is a systolic murmur

Question 16

Maneuvers to increase venous return

Answer 16

lying supine

squatting

lifting legs

Question 17

Maneuvers to decrease venous return

Answer 17

standing

valsalva maneuver

Question 18

Inspiration increases venous return to which side of the heart

Answer 18

Right Side: RINSPIRATION

→ increases the sound of murmurs on the R side

Question 19

Expiration increases venous return to which side of the heart

Answer 19

Left side → increases sound of all murmurs on the L side

Question 20

Increased Total Peripheral Resistance & Murmurs

Answer 20

How to: handgrip, phenylephrine

• increased resistance decreases forward flow & increases backward flow → increases aortic regurg, mitral regurg (regurgitant murmurs)
• decreases AS, MVP, hypertrophic cardiomyopathy

Question 21

Decreased Total Peripheral Resistance & Murmurs

Answer 21

How to: Amyl Nitrate

• direct arteriolar vasodilator increases forward flow through the aortic valve
  
  • increases AS, MVP, hypertrophic cardiomyopathy
  • decreases AR, MR (regurgitant murmurs)

Question 22

What does the pitch tell you about the murmur?

Answer 22

a murmur will be high-pitched if there is a large pressure gradient across the pathologic lesion and low pitched if the pressure gradient is low (Ex. aortic stenosis is high pitched d/t t the large pressure gradient b/w aorta and ventricle

Question 23

Pulsus parvus et tardus

Answer 23

weak, delayed carotid pulse

often seen in Aortic Stenosis