Murmurs Flashcards
pathophysiology of aortic stenosis
LV outflow obstruction leads to a fixed cardiac output, increased after load, left ventricular hypertrophy, and eventually LV failure
what is the most common valvular disease
aortic stenosis
sx aortic stenosis
exertional dyspnea MC sx
decreased exercise tolerance
angina
syncope
CHF
describe the sounds/quality for aortic stenosis
harsh, low pitched, mid-late peaking, systolic, crescendo-decrescendo murmur best heart at the right upper sternal border and radiates to the carotid arteries
when does aortic stenosis increase
sitting while leaning forward
increased venous return (squatting, supine, leg raise)
expiration
decreased after load (inhalation of amyl nitrate)
when does aortic stenosis decrease
decreased venous return (valsalva, standing)
inspiration
increased afterload (handgrip)
PE aortic stenosis
weak, delayed carotid pulse
narrow pulse pressure
fourth heart sound (S4)
Test of choice for aortic stenosis and what will it show
echocardiogram
small aortic orifice
LVH
thickened/calcified aortic valve
what will you see on EKG for aortic stenosis
LVH
definitive diagnosis for aortic stenosis
cardiac catheterization
only effective tx for aortic stenosis
aortic valve replacement
aortic regurgitation
incomplete aortic valve closure leading to regurgitation of blood through the aortic valve into the left ventricle during diastole
two most common causes of aortic regurgitation
endocarditis
aortic dissection
quality/sound of aortic regurgitation
high pitched, blowing, decrescendo or sustained, diastolic murmur best heard over Era’s point
when does aortic regurgitation increase
sitting up while leaning forward
holding breath in end-expiration
increased venous return (squatting, supine, leg raise)
increased after load (handgrip)
when does aortic regurgitation decrease
decreased venous return (valsalva, standing)
inspiration
decreased after load (amyl nitrate)
what else will you see on PE for aortic regurgitation
bounding ulses
pulses bisferiense
wide pulse pressure (increased SBP and decreased DBP)
tx for aortic regurgitation
after load reduction - ACEI, ARBs, Nifedipine, Hydralazine
surgery is definitive
aortic valve replacement for emergency
mitral stenosis
narrowing of the mitral valve orifice leading to obstruction of flow from the left atrium to the left ventricle and back flow of blood into the left atrium
pathophysiology of mitral stenosis
obstruction of flow from LA to LV –> blood backs up into left atrium –> pulmonary congestion –> pulmonary HTN –> CHF
Sx mitral stenosis
exertion dyspnea (MC)
exercise intolerance
hemoptysis
cough
pulmonary HTN
Afib
what are mitral facies commonly seen in mitral stenosis
ruddy (flushed) cheeks with facial pallor (chronic hypoxia)
PE for mitral stenosis
prominent (loud) S1
opening snap
loud P2
sounds/quality mitral stenosis
low-pitched, mid-diastolic, rumbling murmur best heard at the mitral area/apex (left fifth intercostal space at the mid-clavicular line)
increase sound for mitral stenosis
left lateral decubitus position
expiration
increased venous return (squatting, leg raise, lying, supine)
decreased sound mitral stenosis
decreased venous return (valsalva, standing)
inspiration
amyl nitrate
what will EKG show for mitral stenosis
left atrial enlargement
Afib
pulmonary HTN (RVH, right axis deviation)
tx for mitral stenosis
percutaneous balloon valvuloplasty
what is almost always the cause of mitral stenosis
rheumatic heart disease
mitral regurgitation
incomplete closure of mitral valve, leading to retrograde blood from from left ventricle to left atrium during systole
compensatory consequences to mitral regurgitation
left atrial dilation
left ventricular hypertrophy
most common cause of mitral regurgitation
mitral valve prolapse
sx mitral regurgitation
exertional dyspnea
Afib
dyspnea at rest
pulmonary edema
hypotension
tachypnea
hypoxemia
cyanosis
decreased cardiac output
possible cardiogenic shock
sounds/quality of mitral regurgitation
high-pitched, blowing, holosystolic murmur best heard at the apex, often with radiation to the left axilla, sub scapular region, or upper sternal borders
increased mitral regurgitation
left lateral decubitus
expiration
increased venous return (squatting, leg raise, supine)
increased afterload (handgrip)
decreased mitral regurgitation
decreased venous return (valsalva, standing)
inspiration
decreased after load (amyl nitrate)
Tx for mitral regurgitation
after load reducers (ACEI, ARBs, hydralazine, nitrates)
repair is generally preferred over replacement
in what population is mitral valve prolapse MC
young women (15-35 years old)
causes of mitral valve prolapse
myxomatous degeneration - weakened and elongated chord tendineae, mitral annular dilation, thickened leaflet tissue
connective tissue diseases - Marfan or Ehlers-Danlos syndromes, osteogenesis imperfecta
sx for mitral valve prolapse
most asx
if sx - atypical chest pain, palpitations, exertion dyspnea, dizziness, etc
sounds/quality mitral valve prolapse
mid-late systolic click best heard at the apex
earlier click and longer duration MVP
any maneuver that makes LV smaller or decreases preload (valsava, standing)
later click and shorter duration MVP
any maneuver that increases preload (squatting, supine, leg raise)
handgrip
tx for asx MVP
reassurance
tx for MVP w autonomic dysfunction
beta blockers
MC cause of primary pulmonic regurgitation
almost always congenital
Pathophysiology of pulmonary regurgitation
back flow of blood from pulmonary artery to RV –> right sided volume overload
sx pulmonary regurgitation
insignificant
if sx - associated w right sided HF –> hepatic congestion, ascites, jugular venous distention, lower extremity edema
PE for pulmonic regurgitation
Graham steel murmur - brief high-pitched decrescendo early diastolic blowing murmur
heard at left upper sternal border
increased pulmonic regurgitation
inspiration
increased venous return (squatting, supine, leg raise)
decrease pulmonic regurgitation
expiration
decreased venous return
tricuspid stenosis
stenosed valve –> back flow of blood from RV to RA –> right sided heart failure
sound/quality tricuspid stenosis
mid-diastolic murmur at left lower sternal border
increased intensity tricuspid stenosis
increased venous return (squatting, supine, leg raise)
inspiration
PE tricuspid stenosis
opening snap
tricuspid regurgitation
