Murmurs Flashcards
Ejection systolic murmur
Aortic stenosis
Pulmonary stenosis, hypertrophic obstructive cardiomyopathy (HOCM)
Atrial septal defect, tetralogy of Fallot
Pansystolic murmur
Mitral/tricuspid regurgitation (high-pitched and ‘blowing’ in character)
Ventricular septal defect (‘harsh’ in character)
Late systolic murmur
Mitral valve prolapse
Coarctation of aorta
Early diastolic murmur
Aortic regurgitation (high-pitched and 'blowing' in character) Graham-Steel murmur (pulmonary regurgitation, high-pitched and 'blowing' in character)
Mid-late diastolic murmur
Mitral stenosis ('rumbling' in character)
Austin-Flint murmur (severe aortic regurgitation, 'rumbling' in character)Continuous machine-like murmur
Patent ductus arteriosus
Aortic stenosis
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
Mitral stenosis
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
S3
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
S4
Caused by atrial contraction against a stiff ventricle
Heard in aortic stenosis, HOCM, hypertension
S1
Closure of mitral and tricuspid valves
Soft if long PR or mitral regurgitation
Loud in mitral stenosis
Mitral regurgiation
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
Aortic regurgitation
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
S2
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
Pulsus paradoxus
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
Slow-rising/plateau pulse
Aortic stenosis
Collapsing pulse
Aortic regurgitation, patent ductus arteriosus, hyperkinetic (anaemia, thyrotoxic, fever, exercise/pregnancy)
Pulsus alternans
Regular alternation of the force of the arterial pulse
Severe LVF
Bisferiens pulse
‘Double pulse’ - two systolic peaks
Mixed aortic valve disease, HOCM
‘Jerky’ pulse
HOCM
Left bundle branch block
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
Right bundle branch block
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
Left axis deviation
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
Right axis deviation
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
PR interval
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
T waves
Peaked - hyperkalaemia, myocardial ischaemia
Inverted - myocardial ischaemia, digoxin toxicity, subarachnoid haemorrhage, arrhythmogenic right ventricular cardiomyopathy, pulmonary embolism (‘S1Q3T3’), Brugada syndrome
ST segment
Depression - secondary to abnormal QRS (LVH, LBBB, RBBB), ischaemia, digoxin, hypokalaemia, syndrome X
Long QT syndrome
Causes - hypocalcaemia, hypokalaemia, hypomagnesaemia, acute MI, myocarditis, hypothermia,
subarachnoid haemorrhage
