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CAM II > Murmurs > Flashcards

Murmurs Flashcards

1
Q

Ventricular systole

A

The interval between the 1st (S1) and 2nd (S2) heart sounds

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2
Q

Ventricular diastole

A

The interval between the 2nd (S2) and 1st (S1) heart sounds

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3
Q

What is the first heart sound (S1) associated with?

A

Mitral and tricuspid valve closure

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4
Q

What is the 2nd heart sound (S2) associated with?

A

Aortic and pulmonic valve closure

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5
Q

Sysolic clicks

A

Ejection sounds produced in mid to late systole

MC associated with MVP

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6
Q

Opening snap

A

The opening of abnormal mitral or tricuspid valves in the presence of rheumatic valvular stenosis

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7
Q

How can cardiac murmurs be described?

A 
Intensity through grade
Pitch
Quality
Timing
Shape (crescendo, etc.)
Location
Radiation
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8
Q

Grades of murmurs

A

I- the faintest murmur that can be heard (with difficulty)
II- faint but can be identified immediately
III- moderately loud; NO thrill
IV- loud and is associated with a palpable thrill
V- very loud but cannot be heard without the stethoscope
VI- Loudest and can be heard without a stethoscope

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9
Q

How can the majority of heart murmurs be categorized?

A

Midsystolic and soft (grades I-II)

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10
Q

Which murmurs always need to be worked up?

A

Loud, holosystolic or late systolic murmurs, diastolic murmurs or continuous murmurs

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11
Q

Innocent murmurs

A

Grade 1-2 (mid) systolic ejection murmurs
NEVER
-Grade 4 or more
-Pansystolic
-Diastolic
-Continuous
-Other abnormal sounds - e.g. fixed splits S2

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12
Q

Venous hums

A

High flow states- e.g. anemia

Goes away when lying down

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13
Q

L-sided heart failure sx

A 
PND
Elevate PCWP
Pulmonary congestion
-Cough
-Crackles
-Wheezes
-Blood-tinged sputum
-Tachypnea
Restlessness
Confusion
Orthopnea
Exertional dyspnea
Fatigue
Cyanosis
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14
Q

Rt-sided heart failure sx

A 
Fatigue
Increased peripheral venous pressure
Ascites
Hepatosplenomegaly
May be secondary to chronic pulmonary problems
JVD
Anorexia and complaints of GI distress
Weight gain
Dependent edema
Peripheral and facial cyanosis
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15
Q

What is the #1 cause of R ventricular failure?

A

L ventricular failure

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16
Q

Main systolic murmurs

A

Mitral regurg

Aortic stenosis

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17
Q

Other systolic murmurs

A 
Tricuspid regurg
Pulmonic stenosis
VSD
HCM
ASD
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18
Q

Main diastolic murmurs

A

Aortic regurg

Mitral stenosis

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19
Q

Other diastolic murmurs

A

Pulmonic regurg

Tricuspid stenosis

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20
Q

Aortic stenosis

A

Narrowing of the aortic valve
Etiology
-Congenital (uni- or bicuspid valve)
-Calcification/degeneration

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21
Q

Risk factors for aortic stenosis

A

HTN
Hypercholesterolemia
Smoking

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22
Q

S/sx of aortic stenosis

A

SAD- syncope, angina, dyspnea
Chest discomfort
Heart failure/death
Dyspnea and decreased exercise tolerance
-MC symptom
-Diastolic dysfunction with an increase in LV filling pressures with exercise
-Inability of the LV to increase the CO during exercise

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23
Q

Characteristics of aortic stenosis

A

Crescendo-decrescendo harsh murmur
-Ejection murmur
-Late peaking = more severe
Radiates in forward direction to carotids
Possible decreased or absent 2nd heart sound
-Soft and single S2
Possible S4

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24
Q

Diagnostics for aortic stenosis

A

Delayed carotid upstroke
CXR-usually nl
EKG- LVH, +/-Left atrial enlargement (LAE)
Echo- valve size and gradient
-Severe AS= valve area <1.0 cm squared, jet velocity over 4.0 m/sec, mean transvalvular gradient greater than or equal to 40 mmHg

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25
Q

Indication of LVH in EKG

A

Very tall R wave in V5 and V6

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26
Q

Staging of valvular disease

A

A is least, D is worst

C is asymptomatic, D is symptomatic

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27
Q

Medications for aortic stenosis

A

Diuretics

Beta-blockers

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28
Q

Surgery/procedures for aortic stnosis

A

Aortic valve replacement
-Tissue vs mechanical
Balloon valvuloplasty
Transcatheter aortic valve replacement (TAVR)

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29
Q

Complication of balloon valvuloplasty

A

Can cause calcium breakoff

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30
Q

Tissue valves

A

Last 10-15 yrs
Bovine or porcine
Porcine is gold standard
Anticoagulation not required

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31
Q

Mechanical valves

A

Last 1,000 years
Made of titanium or pyrolytic carbon
Warfarin anticoagulation REQUIRED

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32
Q

What is indicated for both types of valves?

A

Endocarditis prophylaxis

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33
Q

What is the gold standard for entrance of catheter for a TAVR?

A

Femoral artery

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34
Q

Ross procedure

A

Cut out pulmonic valve and put it into aortic position. Put cadaver or tissue valve in pulmonic position
Pros- their own tissue, shouldn’t need to be replaced. Other valves lasts 30-40 yrs

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35
Q

Mitral regurg causes

A 
MVP
Ischemia/infarction
-MI with ruptured chordae tendinae
-Ischemia is responsible for 3-25% of MR, severity is directly proportional tot he amount of LV hypokinesis
Acute rheumatic heart disease
Calcification
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36
Q

Mitral valve prolapse

A

Floppy, degenerative, or myxomatous

Seen in up to 10% of healthy young women

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37
Q

S/sx of MVP

A

Asymptomatic
Nonspecific CP, dyspnea, fatigue, or palpitations
Possible skeletal deformities (pectus excavatum, scoliosis)
Mid-systolic click +/- systolic murmur

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38
Q

Diagnostics for MVP

A

Echo

39
Q

Medications for MVP

A

Beta blockers

40
Q

Surgery for MVP

A

Mitral valve repair > mitral valve replacement

41
Q

S/sx of mitral regurg

A

Acute-pulmonary edema signs
Chronic- exertional dyspnea, fatigue over time
Palpitations- possible a-fib

42
Q

Characteristics of mitral regurg

A

Pansystolic murmur (high-pitched “blowing”)
-Radiates to the axilla
Possible S3

43
Q

Diagnostics for mitral regurg

A 
Lab
-BNP: early identifier of LV dysfunction
Echo
-Regurgitant volume
-Ejection fraction
-LA size
-LV size, PA pressure, RV function
44
Q

Medical mitral regurg tx

A

Diuretics and beta blockers
Vasodilators like ACE-I often helpful
Warfarin for a-fib

45
Q

Surgery for mitral regurg

A

Acute case-emergent surgery
-Stabilize first with vasodilators and/or intra-aortic balloon pumps
Chronic cause- elective surgery
-Data proves early surgery indicated even in asymptomatic pts (depends on LV function)
-Best results are achieved in pts with an EF >60% and an end-systolic size <4.5 cm

46
Q

Indications for intra-aortic balloon pump (IABP)

A

Myocardial ischemia/infarction

Mitral regurg

47
Q

Contraindications for intra-aortic balloon pump (IABP)

A

Aortic insufficiency
Aortic dissection
Severe aortic atherosclerosis

48
Q

Primary care f/u for mitral regurg

A

Pts with ONLY mild MR and no evidence of LV enlargement, LV dysfunction, or pulmonary htn should undergo echocardiography every 3-5 yrs
Refer all other pts to cardiology for more frequent f/u

49
Q

Etiology of aortic regurg

A 
Rheumatic-rare
Nonrheumatic
-HTN
-Bicuspid valve
-Infective endocarditis
-Marfan syndrome
-Aortic dissection
-Inflammatory diseases
50
Q

S/sx of aortic regurg

A 
Asymptomatic
Exertion dyspnea
Fatigue
Atypical CP
Eventual LV failure
51
Q

Pathophysiology of aortic regurg

A

Increased SV
-Bounding pulses with rapid rise and fall
–Water-hammer pulse or Corrigan pulse
–Quincke pulses (nailbed capillar pulsations)
–Musset sign (head bob with each pulse)
–Hill sign (40 mmHg higher BP in the LE compared to UE)
Wide pulse pressure
-Elevated systolic and low diastolic pressure

52
Q

Corrigan pulse

A

Characterized by a rapidly swelling and falling arterial pulse. This finding is generally best appreciated by palpation of the radial or brachial arteries (exaggerated
by raising the arm) or the carotid pulses

53
Q

deMusset’s sign

A

A head bob occurring with each heart beat

54
Q

Traube’s sign

A

A pistol shot pulse (systolic and diastolic sounds) heard over the femoral arteries

55
Q

Duroziez’s sign

A

A systolic and diastolic bruit heard when the femoral artery is partially compressed

56
Q

Quincke’s pulse

A

Capillary pulsations in the fingertips or lips

57
Q

Mueller’s sign

A

Systolic pulsations in the uvula

58
Q

Becker’s sign

A

Visible pulsations of the retinal arteries and pupils

59
Q

Hill’s sign

A

Popliteal cuff systolic pressure exceeding brachial pressure by more than 20 mmHg with pt in the recumbent position

60
Q

Mayne’s sign

A

More than a 15 mmHg decrease in diastolic BP with arm elevation from the value obtained with the arm in the standard position

61
Q

Rosenbach’s sign

A

Systolic pulsations of the liver

62
Q

Gerhard’s sign

A

Systolic pulsations of the spleen

63
Q

Characteristics of aortic regurg

A

High-pitched and decrescendo diastolic murmur
Radiates to the apex
Better heard when sitting and leaning forward
+/- Austin Flint murmur
-Due to partial closing of the anterior leaflet of the mitral valve

64
Q

Diagnostics of aortic regurg

A

EKG- LVH

Echo-regurgitant volume

65
Q

Tx of aortic regurg

A 
Medical- diuretics, BBs, nifedipine, ACE-I
-ARBs with Marfan disease
Surgery- aortic valve replacement
-Aortic root replacement
-Ross procedure
66
Q

Indications for valve replacement in pts with severe aortic regurg

A
  1. The onset of sx
  2. LV dysfunction (EF <50%) and
  3. severe LV dilatation (end-systolic size >5.5 cm)
67
Q

Mitral stenosis

A

The MV leaflets thicken, the commissures fuse, calcium deposits on the valve, and the chordae tendinae thicken and shorten

68
Q

Etiology of mitral stenosis

A

Almost always the result of rheumatic fever
-2/3 are female pts
Less common causes include congenital MS, SLE, RA, atrial myxoma, and bacterial endocarditis.

69
Q

S/sx of severe mitral stenosis

A 
DOE- most common complaint
-D/t pulmonary venous hypertension
Palpitations
Atrial fib
Cough
Orthopnea
CP
Thromboembolism
70
Q

PE of mitral stenosis

A 
Pulmonary edema (rales)
\+/- irregularly irregular heart rate
Left and possible right heart failure sx
Cutaneous vasoconstriction results in pinkish-purple patches on the cheeks
Mallor rash- lupus is in differential
71
Q

Murmur characteristics of mitral stenosis

A

Diastolic murmur (low-pitched rumbling)
-Best heard in left lateral decubitus position
Opening snap
-Extra diastolic sound that follows A2
Pulmonary hypertension
-If present, +/- RV lift; an increased pulmonic S2 sound; and a high-pitched, decrescendo, diastolic murmur of pulmonary insufficiency

72
Q

CXR findings for mitral stenosis

A 
Left atrial enlargement
-Straightening of the left heart border
-Retrocardiac double density
-Elevation of left bronchus
\+/- enlarged pulmonary artery
\+/- calcification in mitral valve area
73
Q

EKG findings in mitral stenosis

A 
Atrial fib is common
Left atrial enlargement
-P mitrale
-Broader P wave in lead II that is notched
\+/- RAD
\+/- RVH
74
Q

What is the most sensitive and specific noninvasive test for mitral stenosis?

A

Echocardiography

75
Q

Echo findings for mitral stenosis- valve area

A

Mild: >1.5 cm squared
Moderate: 1.0-1.5 cm squared
Severe: <1.0 cm squared

76
Q

Medical tx of mitral stenosis

A

Diuretics and beta blockers
-Diuretic (usually loop) for pulmonary vascular congestion
-Beta blockers for heart rate control
-CCB if BB contraindicated, digoxin for rate control of a fib
Warfarin for a fib or left atrial thrombus
-INR goal: 2.5

77
Q

Non-surgical tx of mitral stenosis

A

Percutaneous mitral balloon commissurotomy (PMBC)

78
Q

Surgical tx of mitral stenosis

A

Open mitral commissurotomy and valve repair
Mitral valve replacement +/- MAZE procedure
-Tissue vs. mechanical
-+/- Maze procedure
-+/- left atrial appendage amputation

79
Q

Etiology of tricuspid stenosis

A

Rheumatic
Carcinoid syndrome
Fen-Phen

80
Q

S/sx of tricuspid stenosis

A

Right heart failure
Giant a wave seen in the JVP
Diastolic rumble murmur
-Increases with inspiration

81
Q

Diagnostics of tricuspid stenosis

A

EKG- RA enlargement
CXR- cardiomegaly, dilated SVC
Echo- stenosis

82
Q

When does tricuspid regurgitation occur?

A 
Occurs whenever there is RV dilation from any cause
Pulmonary valvular stenosis
Pulmonary HTN
Cardiomyopathy
RCA myocardial infarction
Heart failure
Endocarditis
83
Q

S/sx of tricuspid regurgitation

A

Right-sided heart failure
JVP- x wave becomes obliterated
Systolic murmur that increases with inspiration

84
Q

Diagnostics of tricuspid regurgitation

A

EKG- RA enlargement

Echocardiogram

85
Q

Tx of tricuspid regurgitation

A 
Diuretics
-Aldosterone antagonists if ascites
Tricuspid annuloplasty
Valve replacement
-Bioprosthetic valve (no anticoagulation)
86
Q

S/sx of pulmonary valve stenosis

A

DOE
CP
Eventual RV failure

87
Q

PE of pulmonary valve stenosis

A

Palpable parasternal lift d/t RV hypertrophy
Loud, harsh systolic murmur +/- thrill (2nd ICS)
-Increases with inspiration
Ejection click that precedes the murmur
-Decreases with inspiration
-P2 delayed and soft or absent

88
Q

Diagnostics of pulmonary valve stenosis

A

EKG: +/- RAD, RVH
Echo: diagnostic tool of choice

89
Q

Tx of pulmonary valve stenosis

A

Symptomatic pts with peak gradient >60 mm
Percutaneous balloon valvuloplasty
Surgical commissurotomy or pulmonary valve replacement

90
Q

Etiology of pulmonary valve regurgitation

A

Most cases are d/t pulmonary hypertension
Abnormal valve
Plaque from carcinoid disease
Post-surgical Tetralogy of Fallot repair

91
Q

S/sx of pulmonary valve regurg

A 
Most are asymptomatic
Hyperdynamic RV
-RV heave, lift
2nd heart sound may be widely split
Diastolic murmur increases with inspiration
92
Q

Diagnostic of pulmonary valve regurg

A

Echo

93
Q

Tx of pulmonary valve regurg

A

Diuretics
Pulmonary valve replacement
-If RV enlargement or dysfunction is present

CAM II (3 decks)

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