Murmurs Flashcards
Aortic stenosis murmur: sounds
- ejection systolic
- radiates to carotids
- louder on expiration
- soft/absent S2
- S4
Aortic stenosis: signs
- chest pain
- dyspnoea
- syncope/dizziness
- narrow pulse pressure
- slow rising pulse
- thrill
Aortic stenosis: causes
- degenerative calcification (>65)
- biscupsid aortic valve (<65)
- post rheumatic disease
- HOCM (subvalvular)
- William’s syndrome
Aortic stenosis: management
- Asymptomatic & valvular gradient <40 = observe
- symptomatic/asymptomatic & valvular gradient >40 = surgery
- AVR/balloon valvuloplasty
- Balloon valvuloplasty = for children w no calcification or adults who are not fit for AVR
Surgical AVR = for young/low risk pt
Transcatheter AVR = high risk pt
Aortic regurgitation: murmur
- Early diastolic
- Mid-late diastolic = Austin-Flint mumur in severe AVR
Aortic regurgitation: signs
- Collapsing pulse
- Wide pulse pressure
- Quincke’s sign (nailbed)
- De musset’s (head bobbing)
Aortic regurg: management
- medical management of any associated heart failure
- surgery: aortic valve indications include:
symptomatic patients with severe AR
asymptomatic patients with severe AR who have LV systolic dysfunction
Aortic regurg: causes
Causes of AR due to valve disease
* rheumatic fever: the most common cause in the developing world
* calcific valve disease
* connective tissue diseases e.g. rheumatoid arthritis/SLE
* bicuspid aortic valve (affects both the valves and the aortic root)
* infective endocarditis
Causes of AR due to aortic root disease:
* bicuspid aortic valve (affects both the valves and the aortic root)
* spondylarthropathies (e.g. ankylosing spondylitis)
* hypertension
* syphilis
* Marfan’s, Ehler-Danlos syndrome
* Aortic dissection
Mitral stenosis: murmur
- mid-late diastolic murmur (best heard in expiration)
- loud S1
- opening snap: indicates mitral valve leaflets are still mobile
mitral stenosis: signs
- dyspnoea
- haemoptysis: may range from pink frothy sputum to sudden haemorrhage secondary to rupture of thin-walled and dilated bronchial veins
- low volume pulse
- malar flush
- atrial fibrillation
- Atrial enlargement on CXR
mitral stenosis: managment
- patients with associated atrial fibrillation require anticoagulation: currently warfarin is still recommended for patients with moderate/severe MS
- asymptomatic patients: monitored with regular echocardiograms
- symptomatic patients: percutaneous mitral balloon valvotomy, mitral valve surgery (commissurotomy, or valve replacement)
Mitral regurgitation: sounds
- pansystolic murmur described as “blowing”
- heard best at the apex and radiating into the axilla
- S1 may be quiet as a result of incomplete closure of the valve
- severe MR may cause a widely split S2
mitral stenosis: causes
- rheumatic fever
Rarer causes that may be seen in the exam include mucopolysaccharidoses, carcinoid and endocardial fibroelastosis
mitral regurg: causes
- Following coronary artery disease or post-MI
- Mitral valve prolapse
- Infective endocarditis
- Rheumatic fever
- Congenital
mitral regurg: signs
- fatigue
- shortness of breath
- oedema
- Asymptomatic mostly
- Cardiomegaly
Mitral regug: management
- Medical management in acute cases involves nitrates, diuretics, positive inotropes and an intra-aortic balloon pump to increase cardiac output
- If patients are in heart failure, ACE inhibitors may be considered along with beta-blockers and spironolactone
- In acute, severe regurgitation, surgery is indicated
- The evidence for repair over replacement is strong in degenerative regurgitation, and is demonstrated through lower mortality and higher survival rates
- When this is not possible, valve replacement with either an artificial valve or a pig valve is considered
mitral prolapse: sound
late systolic murmur
Pulmonary stenosis: sound
ejection systolic murmur, louder on inspiration
widely split S2
Pulmonary regurgitation: sounds
- early diastolic murmur
- graham-steel murmur
- high-pitched & blowing
HOCM: sounds
ejection systolic murmur (functional aortic stenosis)
louder on expiration
increases with valsalva
decreases on squatting
mitral regurg: pansystolic murmur
HOCM: features
- often asymptomatic
- exertional dyspnoea
- angina
- syncope: typically following exercise
- sudden death (most commonly due to ventricular arrhythmias), arrhythmias, heart failure
- jerky pulse, large ‘a’ waves, double apex beat
HOCM: echo findings
mnemonic - MR SAM ASH
mitral regurgitation (MR)
systolic anterior motion (SAM) of the anterior mitral valve leaflet
asymmetric hypertrophy (ASH)
HOCM: managment
ABCDE
* amiodarone
* beta blockers
* cardioverter defib
* dual chamber pacemaker
* endocarditis prophylaxis
* Myomectomy: to remove obstruction
AVOID: nitrates, ACEi, inotropes
VSD: murmur
pan-systolic murmur which is louder in smaller defects
VSD: causes
- congenital VSDs are often association with chromosomal disorders: Down’s syndrome, Edward’s syndrome. Patau syndrome, cri-du-chat syndrome
- congenital infections
- acquired causes: post-myocardial infarction
tricuspid regurgitation: signs
- pan-systolic murmur
- prominent/giant V waves in JVP
- pulsatile hepatomegaly
- left parasternal heave
tricuspid regurg: causes
- right ventricular infarction
- pulmonary hypertension e.g. COPD
- rheumatic heart disease
- infective endocarditis (especially intravenous drug users)
- Ebstein’s anomaly
- carcinoid syndrome
ASD: features
- ejection systolic murmur, fixed splitting of S2
- louder on inspiration
- embolism may pass from venous system to left side of heart causing a stroke
- Most commonly ostium secundum
Aortic SCLEROSIS
- ejection systolic
- more common with age than stenosis
- no radiotion or ECG changes
