Murmurs Flashcards
Easy mnemonic for remembering systolic murmurs
MRS ASS
Mitral Regurgitation
Aortic Stenosis
How do you accentuate murmurs depend on the side?
Left sided - expiration
Right sided - Inspiration
How do you listen to mitral regurgitation?
Listen at axilla with diaphragm while the patient leans to the left
Much commoner than mitral stenosis
Give five causes of mitral regurgitation
- Prolapsing mitral valve
- Rheumatic mitral regurgitation
- Papillary muscle rupture
- Cardiomyopathy
- Connective tissue disorders
What happens to the signs in mitral regurgitation
More likely to be in sinus rhythm
Face -> Malar flush
Palpation -> Displaced Apex beat/palpable thrill
What do you hear on auscultation in mitral regurgitation?
Pansystolic murmur raditating to axilla heard best in the apex with the diaphragm when the patient is leadning to the left.
ECG findings in MR?
Bifid p waves
Left ventricular hypertrophy
Where do you listen for aortic stenosis?
- Listen with diaphragm over aortic valve
- Also listen at base of neck
Give three causes of aortic stenosis
- Calcification of the valve
- Bicuspid aortic valve
- Rheumatic fever
Give the three main symptoms which come on with aortic stenosis
- Loss of consciousness
- Angina
- Shortness of breath (orthopnoea & PND)
What is the pathology of syncope in aortic stenosis?
Syncope may be explained by aortic stenosis generating a fixed cardiac output which cannot compensate for decrease in vascular resistance which comes on in exercise. This reduces blood flow to brain and causes syncope.
Give the pulse, volume and palpation of aortic stenosis
Pulse – Character is slow and rising
Volume – Low volume with narrow pulse pressure
Palpation – Forceful apex beat
What can you hear in auscultation of aortic stenosis
Ejection systolic murmur radiating to carotids
What will you see in aortic stenosis on x-ray?
Chest x-ray will show a relatively small heart with a prominent dilated, ascending aorta -> Post-stenotic dilatation.
What is the aortic stenosis ECG?
ECG will show left ventricular hypertrophy and left ventricular strain pattern.
Where do you listen for aortic regurgitation?
- Aortic area
Give five causes of aortic regurgitation
- Rheumatic fever
- Bicuspid valve
- Infective endocarditis
- Marfan’s syndrome
- Tertiary syphilis
What is the pathology of aortic regurgitation?
Reflux of blood from aorta to LV in diastole. For cardiac output to be maintained, the total stroke volume must be increased, and therefore LV size must increase.
Name three eponymous signs associated with aortic regurgitation
Quicke’s sign
De Musset’s sign
Pistol shot femorale
What is Quincke’s sign?
Capillary pulsation in teh nail beds with aortic regurgitation
What is De Musset’s sign?
Head nodding in aortic regurgitation
What is pistol shot femorale?
A sharp banging heard on auscultation over the femoral arteries in time with each heartbeat
What is the pulse in aortic regurgitation?
Collapsing (wide pulse pressure)
What is auscultation in aortic regurgitation?
High pitched early diastolic murmur best heard at the left sternal edge in the fourth intercostal space with the patient leaning forward and their breath held in expiration.
What happens if aortic regurgitation happens suddenly?
Acutely rapid pulmonary oedema and heart failure. This is treated with immediate aortic valve replacement
Where do you listen for mitral stenosis?
Listen at apex with bell and ask patient to lean to left
What is a common condition that causes mitral stenosis?
Rheumatic fever or chorea occurs in 50% of cases with mitral stenosis
What occurs after you develop mitral stenosis?
High left atrial pressure (loud S1 and AF) leads to pulmonary venous hypertension and subsequently pulmonary arterial pressure (septal lines, cough productive of blood-tinged frothy sputum). This pulmonary hypertension leads to right ventricular hypertrophy, tricuspid regurgitation and the right heart failure.
Give four symptoms of mitral stenosis
Atrial fibrillation and thromboembolism, chest pain and symptoms of heart failure.
Give three signs of mitral stenosis
Atrial fibrillation, malar flush, tapping apex beat due to palpable 1st heart sound.
Gives three causes of mitral stenosis
Rheumatic heart disease, calcification, endocarditis
What do you hear in mitral stenosis?
- Loud S1 (high LA pressure keeps valve pen until late in diastole then slams it shut)
- Opening snap (high pitched sound just after S2).
Outline what happens with the opening S2 snape in Mitral stenosis with increasing severity
- Opening snap (high pitched sound just after S2). If the mitral stenosis is severe, pressure in the LA increases and the mitral valve opens earlier in ventricular diastole. This means that the more severe the mitral stenosis, the shorter the gap between S2 and the opening snap.
- Rumbling mid-diastolic murmur best heard with the bell of the stethoscope held lightly at the apex with the patient lying on the left side.
Give the signs on chest x-ray of pulmonary oedema
o The signs of pulmonary oedema Cardiac size Bat wing pulmonary opacities Presence of peri-bronchial cuffing Septal lines Pleural effusions Upper lobe pulmonary venous diversions
