Murmurs Flashcards
Area for auscultating the Aortic
Aortic: 2nd I.C.S right sternal border
Area for auscultating the Pulmonary
Pulmonary: 2nd I.C.S left sternal border
Area for auscultating the Tricuspid
Tricuspid: 5th I.C.S left sternal border
Area for auscultating the Mitral
Mitral: 5th I.C.S mid clavicular line (apex area)
The first heart sound (S1) is caused by
closure of mitral and tricuspid valves
soft first heart sound is caused by
soft if long PR or mitral regurgitation
loud first heart sound is caused by
loud in mitral stenosis
The second heart sound (S2) is caused by
closure of aortic and pulmonary valves
second heart sound (S2) soft in
soft in aortic stenosis
second heart sound (S2) splitting due to
splitting during inspiration is normal
S3 (third heart sound) is always pathological
false
considered normal if < 30 years old
S3 (third heart sound) may persist in who?
(may persist in women up to 50 years old)
S3 caused by
caused by diastolic filling of the ventricle
S3 is heard in which conditions?
heard in left ventricular failure (e.g. dilated cardiomyopathy) constrictive pericarditis (called a pericardial knock) mitral regurgitation
What is pericardial knock?
S3 sound in constrictive pericarditis
S4 is always normal
false
S4 is caused by ventricular contraction against a stiff ventricle
false
caused by atrial contraction against a stiff ventricle
S4 coincides with which part of the ECG
p waves
S4 is heard in which conditions?
aortic stenosis, hypertension & HOCM
(in HOCM a double apical impulse may be felt as a result of
palpable S4
Aortic stenosis Clinical features of symptomatic disease?
chest pain
dyspnoea
syncope
What type of murmur do you get in aortic stenosis?
delayed ejection systolic murmur
classically radiates to the carotids
aortic stenosis radiating to a carotids is decreased following the Valsalva manoeuvre
true
Pulse in aortic stenosis
narrow pulse pressure & slow rising pulse
Which heart sounds are soft/absent in aortic stenosis
soft/absent S2, S4
Aortic stenosis complications
left ventricular hypertrophy or failure
Causes of aortic stenosis
degenerative calcification (most common cause in older patients > 65 years)
bicuspid aortic valve (most common cause in younger patients < 65 years)
William’s syndrome (supravalvular aortic stenosis)
post-rheumatic disease
subvalvular: HOCM
Management of aortic stenosis if asymptomatic
if asymptomatic then observe the patient is general rule
Management of aortic stenosis if symptomatic
if symptomatic then valve replacement
Management of aortic stenosis and asymptomatic - when is surgery considered?
valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery
Why is angiogram important prior to surgery in aortic stenosis?
Cardiovascular disease may coexist.
For this reason an angiogram is often done prior to surgery so that the procedures can be combined balloon valvuloplasty (limited to patients with critical aortic stenosis who are not fit for valve replacement)
What murmur do you get in Aortic regurgitation
early diastolic murmur:
Aortic regurgitation intesnity of murmur increased by
intensity of the murmur is increased by the handgrip manoeuvre
Aortic regurgitation pulses?
collapsing pulse & wide pulse pressure
Quincke’s sign
(nailbed pulsation) in aortic regurgitation
De Musset’s sign
(head bobbing) in aortic regurgitation
Causes of aortic regurgitation (due to valve disease)
rheumatic fever
infective endocarditis
connective tissue diseases e.g. RA/SLE
bicuspid aortic valve
Causes of aortic regurgitation (due to aortic root disease)
aortic dissection spondylarthropathies (e.g. ankylosing spondylitis) hypertension syphilis Marfan's, Ehler-Danlos syndrome
Atrial flutter is a features of mitral stenosis
false
atrial fibrillation
Mitral stenosis murmur
mid-late diastolic murmur (best heard in expiration)
loud S1, opening snap
mitral stenosis can cause malar flush
true
mitral stenosis pulse
low volume pulse
causes of mitral stenosis?
rheumatic fever, rheumatic fever and rheumatic fever. Rarer causes that may be seen in the exam include mucopolysaccharidoses, carcinoid and endocardial fibroelastosis
Features of severe MS?
length of murmur increases
opening snap becomes closer to S2
CXR & MS?
left atrial enlargement may be seen
Echo & MS?
the normal cross sectional area of the mitral valve is 4-6 sq cm.
A ‘tight’ mitral stenosis implies a cross sectional area of < 1 sq cm
What is Mitral regurgitation
mitral regurgitation (MR) occurs when blood leaks back through the mitral valve on systole mitral valve is located between the left atrium and ventricle, and regurgitation leads to a less efficient heart as less blood is pumped through the body with each contraction.
second most common valve disease after aortic stenosis.
mitral regurgitation
MR is common in otherwise healthy patients to a trivial degree and does not need treatment.
true
Risk factors for MR?
Female sex Lower body mass Age Renal dysfunction Prior myocardial infarction Prior mitral stenosis or valve prolapse Collagen disorders e.g. Marfan's Syndrome and Ehlers-Danlos syndrome
Causes of MR?
Post MI
Infective endocarditis
Rheumatic fever
Congenital
Most patients with MR are asymptomatic
True
Most patients with MR are asymptomatic, and patients suffering from mild to moderate MR may stay largely asymptomatic indefinitely.
MR Symptoms tend to be due to
failure of the left ventricle, arrhythmias or pulmonary hypertension.
This may present as fatigue, shortness of breath and oedema.
MR ECG
ECG may show a broad P wave, indicative of atrial enlargement
MR CXR
Cardiomegaly may be seen on chest x-ray, with an enlarged left atrium and ventricle
MR Echo
Echocardiography is crucial to diagnosis and to assess severity
MR acute mx
Medical management in acute cases involves nitrates, diuretics, positive inotropes and an intra-aortic balloon pump to increase cardiac output
severe- surgery
MR mx dditional drugs for heart failure
If patients are in heart failure, ACE inhibitors may be considered along with beta-blockers and spironolactone
A systolic murmur heard best in the 5th intercostal space is most consistent with?
mitral regurgitation
ascending aortic dissection may cause
aortic regurgitation
Tricuspid regurgitation murmur is systolic/diastolic
systolic
Tricuspid regurgitation murmir is pan systolic
true
Which valve disease presents with left parasternal heave
tricuspid regurgitation
Tricuspid regurgitation presents with which liver symmptom?
pulsatile hepatomegaly
Tricuspid regurgitation causes?
right ventricular infarction pulmonary hypertension e.g. COPD rheumatic heart disease infective endocarditis (especially intravenous drug users) Ebstein's anomaly carcinoid syndrome
A 75-year-old man presents with difficulty breathing at night, occasional palpitations and tight chest pain. On examination, he has a collapsing pulse and a laterally shifted apex beat. You also notice his head bobs in time with his pulse.
This is ?
Aortic regurgitation
