Murmurs

Question 1

Describe the grading system for murmurs?

Answer 1

Grade 1 (I/VI) barely audible Grade 2: faint but immediately audible Grade 3: easily heard Grade 4: easily heard and associated w/ palpable thrill Grade 5: very loud, heard w/ stethoscope lightly on chest Grade 6 (VI/VI): audible w/o stethoscope directly on chest wall

Question 2

Where is the aortic area?

Answer 2

Second to third right intercostal space, next to sternum

Question 3

Where is the pulmonic area?

Answer 3

Second to third left intercostal space, next to sternum

Question 4

Where is the tricuspid area?

Answer 4

Lower-left sternal border

Question 5

Where is the mitral area?

Answer 5

Cardiac apex

Question 6

Full description of a typical aortic stenosis murmur

Answer 6

Grade (intensity) III/VI high-pitched (pitch = frequency), crescendo-decrescendo (shape) systolic (timing) murmur, heard best at the upper-right sternal border (location), with radiation toward the neck

Question 7

How are murmurs described?

Answer 7

-Timing = systolic or diastolic -intensity = grade -shape -location -radiation -response to maneuvers

Question 8

What are the three types of systolic murmurs?

Answer 8

(1) Ejection type- AS, PS (2) Holosystolic- MR, TR, VSD (3) Late systolic- mitral valve prolapse

Question 9

Describe a systolic ejection murmur

Answer 9

• aortic or pulmonic stenosis
• begins after S1 (heart sound one) and terminates before or on S2
• often a crescendo-decrescendo type (intensity rises then falls)

Question 10

Answer 10

Systolic ejection murmur

• indicative of aortic or pulmonic stenosis (think AS b/c much more common)
• starts after S1 (b/c doesnt happen until systole starts (AV valves are closed) and ends before or at S2 (can’t continue when A/P valves are closed)
• crescendo-decrescendo in intensity

Question 11

Explain the volume changes in an AS murmur

Answer 11

Crescendo-decrescendo

• crescendo: rise in LV pressure (increase in flow across AV)
• decresendo: as the LV relaxes (flow decreases => murmur lesses in intensity)

Question 12

When does an ejection murmur start?

Answer 12

Begins in systole shortly after S1

• Ejection murmur (AS or PS).
• gap of time after S1 due to isovolumentric contraction of the LV (period after MV has closed but before the AV has opened)

Question 13

Describe general mindset of systolic murmurs

Answer 13

During systole:

• tricuspid/mitral valves are closed => regurg backwards into atria => TR and MR are systolic murmurs
• aortic/pulmonic valves are open => stenosis prevents optimal forward flow => AS and PS are systolic murmurs
• MV closed => mitral valvae prolapse => late systolic murmur

Question 14

Describe the difference in the murmur heard in mild vs. severe AS

Answer 14

• Mild AS: ejection click close to S1, early peaking in systole, A2 still heard
• as it gets more severe: peak of the murmur becomes more delayed in systole since more force is needed to push blood across the AV, prolonged ventricular ejection delays A2 => A2 merges w/ P2 (no longer comes before P2)
• Severe AS: later peaking in systole, A2 absent b/c of the immobility of the valve leaflets (rigidity, often calcification)

Question 15

Does AS cause a low or high frequency murmur?

Answer 15

High frequency- b/c of the large pressure gradient across the valve

Question 16

Where does an AS murmur radiate?

Answer 16

Toward the neck (direction of the turbulent blood flow)

-can have wide distribution, including to the cardia apex

Question 17

Where does a PS murmur radiate?

Answer 17

Usually doesnt radiate (espeically not as much as AS), but sometimes is transmitted to the neck or left shoulder

Question 18

What benign murmur may young adults have?

Why?

What manuever is helpful?

Answer 18

• young adults often have benign systolic ejection murmurs due to the increased systolic flow across normal aortic and pulmonic valves
• becomes softer or disappears when the pt sits upright (gravity)

Question 19

Answer 19

Pansystolic/holosystolic murmur

-MR, TR, VSD

Question 20

Describe a pansystolic/holosystolic murmur

• intensity
• start time

Answer 20

Pansystolic/holosystolic murmur of MR/TR/VSD

• uniform intensity throughout systole
• they start right at S1 b/c that is right when ventricular pressure > atrial pressure (no gap as seen in ejection murmur)

Question 21

MR murmur

• location
• radiates?

Answer 21

Pansystolic/holosystolic

• high pitched, “blowing” quality
• best heard at the apex
• radiates towards the left axilla
• intensity does not change w/ respiration

Question 22

TR murmur

• location
• radiates

Answer 22

TR pansystolic/holosystolic murmur

• best heart along left lower sternal border
• radiates to the right of the sternum
• high pitched, blowing in quality
• intensity increases w/ inspiration (b/c inspiration enhances venous return => increases RV stroke volume)

Question 23

Differentiate how a MR and TR murmur change w/ breathing

Answer 23

• MR murmur shows no change
• murmur of TR intensifies w/ inspiration: negative pressure in the thoracic cavity increases venous return to the heart => increasing RV stroke volume

Question 24

What does a late systolic murmur indicate?

Answer 24

Most commonly indicates mitral valve prolpase = bowing of abnormally redundant and elongated valve leaflets into the LA during LV contraction

Question 25

Describe the murmur of a VSD

• location
• type

Answer 25

VSD murmur: pan/holosystolic

• best heart at 4th-6th left intercostal space
• high pitched, may be associated w/ palpable thrill

Question 26

What would have a lounder murmur: a large or small VSD

Answer 26

Smaller the VSD, the greater the turbulence of blood flow btwn the LV and RV => murmur of a small VSD would be lounder

Question 27

What is an early diastolic decrescendo murmur typical of?

Answer 27

Aortic regurgitation or pulmonic regurgitation

-early diastolic murmur due to regurgitant flow right when the aortic or pulmonic valve closes

Question 28

AR murmur

Answer 28

Diastolic early decrescendo

Question 29

Mild MS or TS murmur

Answer 29

Diastolic murmur

-mid to late loq frequency rumbling murmur following a sharp opening snap

Question 30

What may cause a continuous murmur?

Answer 30

PDA (patent ductus arteriosus)

-continuous murmur when there is a persistent pressure gradient btwn 2 structures during both systole and diastole