Murmurs

Question 1

What is a murmur?

Answer 1

direct result of blood flow turbulence

Question 2

The amount of turbulence =

Answer 2

intensity of the murmur

Question 3

Where are mitral murmurs best heard at?

Answer 3

the apex

Question 4

Atrial septal defect is ________

Answer 4

diastolic

Question 5

Ventricular septal defect is ______

Answer 5

systolic

Question 6

Intensity of a murmur

Answer 6

determined by the quantity and velocity (turbulence)

Question 7

Factors that affect turbulence of a murmur

Answer 7

The size of the orifice or vessel through which the blood flows
The pressure difference (gradient)
The volume of blood

Question 8

The transmission of intensity of a murmur is also dependent on the characteristic of tissue between the blood flow and the stethoscope. Explain high and low intensities

Answer 8

Higher intensity: Low BMI individuals
Lower intensity: Air (emphysema), fluid (pericardial effusion), fat (high BMI)

Question 9

What are the grades of intensity of a murmur and what does each mean?

Answer 9

Grade I: very faint
Grade II: soft murmur, readily detectable
Grade III: loud but no palpable thrill
Grade IV: loud with palpable precordial thrill
Grade V: very loud, audible with stethoscope lightly on the chest with a palpable precordial thrill
Grade VI: loudest murmur, audible WITHOUT a stethoscope, + palpable thrill

Question 10

Describe pitch, high/low

Answer 10

High pitch: best heard with diaphragm
Low pitch: best heard with bell

Question 11

Describe what the quality of a murmur can be

Answer 11

Harsh, rumbling, blowing, musical

Question 12

What are configurations of murmurs?

Answer 12

Configuration: The time course of murmur intensity

Crescendo: Increasing

Decrescendo: Decreasing

Crescendo-decrescendo: Increases then decreases

Plateau: Intensity doesn’t change

Question 13

How is the duration of a murmur assessed?

Answer 13

by determining the timing of the murmur relative to the cardiac cycle

Question 14

What are systolic murmurs?

Answer 14

starts with or after S1 and terminates with or before S2

Question 15

Early systolic murmur

Answer 15

Obscures S1, does not extend to S2

Question 16

Mid systolic murmur

Answer 16

begins after S1, ends before S2 (both S1 and S2 easily audible)

Question 17

Holosystolic (pansystolic) murmur

Answer 17

obscures both S1 and S2, lasts entire duration

Question 18

Late systolic murmur

Answer 18

starts after S1, extends to S2

Question 19

What are systolic murmurs?

Answer 19

Mitral regurgitation
Tricuspid regurgitation
Aortic stenosis
Pulmonic stenosis
Ventricular septal defect
Hypertrophic obstructive cardiomyopathy

Question 20

Mitral regurgitation

Answer 20

The mitral valve is a bicuspid valve

The valve opening is enclosed by a fibrous ring = mitral valve annululs

The mitral valve leaflets are attached to chordae tendineae
Tendon-like projections that prevent prolapse of leaflets and regurgitation of blood back into the left atrium

The chordae tendineae are further attached to papillary muscles that attach to the left ventricular walls

Question 21

What is mitral regurgitation caused by?

Answer 21

a leaky, or incompetent, valve causing backwards flow of blood from the left ventricle into the left atrium

Question 22

What are the primary causes of mitral valve regurgiation?

Answer 22

Mitral valve prolapse
Ischemic (coronary artery disease)
Rheumatic heart disease
Endocarditis

Question 23

What are the secondary causes of mitral valve regurgitation?

Answer 23

The result of progressive enlargement of the left ventricle leading to mitral annular dilatation and displacement of the papillary muscles

Question 24

Mitral valve regurgitation (systolic murmur)

Answer 24

Timing: Early systolic or holosystolic

Location: Apex

Radiation: Axilla

Intensity correlates with severity

Quality: High pitched, blowing

Pitch: Medium

Question 25

For the mitral regurgitation (systolic murmur), ______ is soft due to poor closure of the MV

Answer 25

S1

Question 26

During the mitral regurgitation (systolic murmur), ________ and _______ are present due to volume overload

Answer 26

ventricular gallop (S3), atrial gallop (S4)

Question 27

What are the associated clinical findings with mitral regurgitation (systolic murmur)

Answer 27

Hyperdynamic or displaced apical impulse (PMI) Heart failure if degree of MR is severe Atrial fibrillation is common

Question 28

What is mitral valve prolapse?

Answer 28

the mitral valve may have redundant or elongated chordae tendineae causing an abnormal ballooning of the mitral valve leaflets during systole

Question 29

MVP is associated with a ______ click

Answer 29

systolic, as the leaflets snap back into place

Question 30

MVP is associated with a murmur ONLY when ______ is present as well, typically mid to late systolic

Answer 30

Mitral regurgitation

Question 31

What is the most common cause of mitral regurgitation?

Answer 31

MVP

Question 32

What is aortic stenosis?

Answer 32

The normal aortic valve opens completely during systole, allowing outflow of blood from the LV Aortic leaflets will calcify over time, causing the valve to narrow

Question 33

The aortic valve is usually _______ but can also be ________ or ________

Answer 33

tricuspid, bicuspid or unicuspid

Question 34

Symptom onset of valvular aortic stenosis

Answer 34

Unicuspid: early childhood Bicuspid: 40-70 years of age Tricuspid: 70+

Question 35

Aortic stenosis (systolic murmur)

Answer 35

Timing: Midsystolic, crescendo-decrescendo Location: Right 2nd intercostal space (aortic area) Radiation: Neck Intensity correlates with severity Quality: Harsh, rough Pitch: Low, but becomes high pitched when very severe

Question 36

T/F Aortic stenosis has thrills that may be palpable

Answer 36

True

Question 37

Aortic stenosis has complete loss of _______

Answer 37

S2

Question 38

Aortic stenosis has an early ___________ due to heavily calcified valve

Answer 38

systolic click

Question 39

What are the associated clinical findings with aortic stenosis?

Answer 39

Angina Syncope Exertional dyspnea Heart failure

Question 40

Ventricular septal defect is a _______ defect

Answer 40

congenital

Question 41

What type of murmur is VSD?

Answer 41

holosystolic from a continuous right shunt during systole

Question 42

VSD is _______, often easily detectable

Answer 42

loud

Question 43

Which murmur can many patients tolerate into adulthood with good functional status?

Answer 43

VSD

Question 44

VSD(stytolic murmur)

Answer 44

Timing: Holosystolic Location: Left or right 3rd/4th intercostal spaces Radiation: left clavicle Intensity: Loud, may have a thrill Quality: Harsh Pitch: low pitch – small defects ; high pitch – larger defects

Question 45

What is tricuspid regurgitation?

Answer 45

Backwards flow of blood from the right ventricle back into the right atrium during systole

Question 46

What are the primary causes of Tricuspid regurgitation?

Answer 46

1. Endocarditis 2. Myocardial infarction > RV dilatation >valve incompetence 3. Right ventricular pacemaker leads (iatrogenic)

Question 47

What are the secondary causes of tricuspid regurgitation?

Answer 47

Pulmonary artery hypertension

Question 48

Tricuspid regurgitation (Systolic murmur)

Answer 48

Timing: Holosystolic Location: Left lower sternal border, 4th intercostal space (tricuspid area) Radiation: Epigastric area Intensity: Increases during inspiration due to increased right sided venous return, decreased with Valsalva Quality: soft, often difficult to hear Pitch: High pitch

Question 49

What are the associated clinical findings with tricuspid regurgitation?

Answer 49

1. PMI may be displaced to epigastric area if RV very enlarged 2. May have a wide split S2 3. S3 or S4 originating from the right side of the heart 4. Findings consistent with right heart failure -JVP -Ascites, abdominal distension -Lower extremity edema