Murmurs

Question 1

Ejection systolic murmur

Answer 1

Aortic stenosis
Pulmonary stenosis, hypertrophic obstructive cardiomyopathy (HOCM)
Atrial septal defect, tetralogy of Fallot

Question 2

Pansystolic murmur

Answer 2

Mitral/tricuspid regurgitation (high-pitched and ‘blowing’ in character)
Ventricular septal defect (‘harsh’ in character)

Question 3

Late systolic murmur

Answer 3

Mitral valve prolapse

Coarctation of aorta

Question 4

Early diastolic murmur

Answer 4

Aortic regurgitation (high-pitched and 'blowing' in character)
Graham-Steel murmur (pulmonary regurgitation, high-pitched and 'blowing' in character)

Question 5

Mid-late diastolic murmur

Answer 5

Mitral stenosis ('rumbling' in character)
Austin-Flint murmur (severe aortic regurgitation, 'rumbling' in character)

Question 6

Continuous machine-like murmur

Answer 6

Patent ductus arteriosus

Question 7

Aortic stenosis

Answer 7

Chest pain, dyspnoea, syncope
Left ventricular hypertrophy, left axis deviation
Narrow pulse pressure, slow rising pulse, delayed ESM, soft/absent S2, S4, thrill, duration of murmur, left ventricular hypertrophy or failure, associated with LBBB
Causes - degenerative calcification (common in older patients > 65 years), bicuspid aortic valve (common in younger patients < 65 years), William’s syndrome (supravalvular aortic stenosis), post-rheumatic disease, HOCM
Severity markers - slow rising pulse, soft S2, palpable S4
Mx - asymptomatic + valvular gradient < 40 - observe; asymptomatic + valvuar gradient > 40 - surgery; symptomatic - valve replacement
Balloon valvuloplasty only for patients with critical aortic stenosis who are not fit for valve replacement

Question 8

Mitral stenosis

Answer 8

Mid-late diastolic murmur (best heard in expiration), loud S1, opening snap, low volume pulse, malar flush, atrial fibrillation, tapping apex beat (same as a palpable S1)
Severe MS - length of murmur increases, opening snap becomes closer to S2
CXR - left atrial enlargement
ECho - 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

Question 9

S3

Answer 9

Caused by diastolic filling of the ventricle
Normal if < 30 years old (may persist in women up to 50 years old)
Heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation

Question 10

S4

Answer 10

Caused by atrial contraction against a stiff ventricle

Heard in aortic stenosis, HOCM, hypertension

Question 11

S1

Answer 11

Closure of mitral and tricuspid valves
Soft if long PR or mitral regurgitation
Loud in mitral stenosis

Question 12

Mitral regurgiation

Answer 12

Due to MI, rheumatic heart disease, infective endocarditis, mitral valve prolapse, calcification, amyloidosis
Displaced apex beat, apical thrill, quiet S1, pansystolic murmur radiating to axilla, S3, thrusting apex beat, loud P2 (due to pulmonary hypertension)
Severity markers - atrial fibrillation, S3, congestive cardiac failure, pulmonary hypertension
Valvotomy scar
Can cause atrial fibrillation

Question 13

Aortic regurgitation

Answer 13

Corrigan’s sign (visible neck veins), De Musset sign (head nodding with heart beat), Quinkes sign (capillary pulsation in nail bed), Muller’s sign (pulsation of the uvula), Traube’s sign (pistol shot femoral pulses), Duroziez sign (
Collapsing pulse, dynamic apex, early diastolic murmur, systolic flow murmur, Austin Flint murmur (mid diastolic murmur)
Associated with Marfan’s syndrome, ankylosing spondylitis, reactive arthritis, endocarditis, rheumatic fever, syphilis

Question 14

S2

Answer 14

Closure of aortic and pulmonary valves
Splitting during inspiration is normal
Soft in aortic stenosis
Loud in hypertension
Fixed split in atrial septal defect
Widely split in deep inspiration, RBBB, pulmonary stenosis, severe mitral regurgitation
Reverse split in LBBB, severe aortic stenosis, right ventricular pacing, WPW type B (causes early P2), patent ductus arteriosus

Question 15

Pulsus paradoxus

Answer 15

Greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration
Severe asthma, cardiac tamponade, left ventricular free wall rupture

Question 16

Slow-rising/plateau pulse

Answer 16

Aortic stenosis

Question 17

Collapsing pulse

Answer 17

Aortic regurgitation, patent ductus arteriosus, hyperkinetic (anaemia, thyrotoxic, fever, exercise/pregnancy)

Question 18

Pulsus alternans

Answer 18

Regular alternation of the force of the arterial pulse

Severe LVF

Question 19

Bisferiens pulse

Answer 19

‘Double pulse’ - two systolic peaks

Mixed aortic valve disease, HOCM

Question 20

‘Jerky’ pulse

Answer 20

HOCM

Question 21

Left bundle branch block

Answer 21

V1 - deep, sharp trough followed by a biphasic hill
V6 - ‘M’ formation of QRS complex
Causes - ischaemic heart disease, hypertension, aortic stenosis, cardiomyopathy
Rare causes - idiopathic fibrosis, digoxin toxicity, hyperkalaemia
New LBBB -> MI

Question 22

Right bundle branch block

Answer 22

V1 - small upward peak, sharp downward trough, sharp upward peak with each wave getting bigger
V6 - pretty normal, more pronounced s wave (after big peak and before t wave)
Causes - normal variant - more common with increasing age, right ventricular hypertrophy, chronically increased right ventricular pressure (e.g. cor pulmonale), pulmonary embolism, myocardial infarction, atrial septal defect (ostium secundum), cardiomyopathy or myocarditis

Question 23

Left axis deviation

Answer 23

Left anterior hemiblock, left bundle branch block, Wolff-Parkinson-White syndrome* - right-sided accessory pathway, hyperkalaemia, congenital - ostium primum ASD, tricuspid atresia
Minor LAD in obese people

Question 24

Right axis deviation

Answer 24

Right ventricular hypertrophy, left posterior hemiblock, chronic lung disease → cor pulmonale, pulmonary embolism, ostium secundum ASD, Wolff-Parkinson-White syndrome* - left-sided accessory pathway, normal in infant < 1 years old
Minor RAD in tall people

Question 25

PR interval

Answer 25

Prolonged - idiopathic, ischaemic heart disease, digoxin toxicity, hypokalaemia, hyperkalaemia, rheumatic fever, aortic root pathology e.g. abscess secondary to endocarditis, Lyme disease, sarcoidosis, myotonic dystrophy
Shortened - Wolff-Parkinson-White syndrome

Question 26

T waves

Answer 26

Peaked - hyperkalaemia, myocardial ischaemia
Inverted - myocardial ischaemia, digoxin toxicity, subarachnoid haemorrhage, arrhythmogenic right ventricular cardiomyopathy, pulmonary embolism (‘S1Q3T3’), Brugada syndrome

Question 27

ST segment

Answer 27

Depression - secondary to abnormal QRS (LVH, LBBB, RBBB), ischaemia, digoxin, hypokalaemia, syndrome X

Question 28

Long QT syndrome

Answer 28

Causes - hypocalcaemia, hypokalaemia, hypomagnesaemia, acute MI, myocarditis, hypothermia,
subarachnoid haemorrhage