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Cardiology > Murmurs > Flashcards

Murmurs Flashcards

1
Q

What is the S1 heart sound?

  • when may it be louder?
  • when may it be softer?
A

Mitral and tricuspid valve closure

  • Occurs when ventricular pressure exceeds atrial pressure
  • Usually single
  • onset of systole
  • usually single or narrowly split

Loud in

  • Thin patients
  • Hyperdynamic circulation (anaemia, pregnancy, thyrotoxicosis)
  • Mitral stenosis

Soft in:

  • Obesity
  • Emphysema
  • heart failure
  • Pericardial effusion
  • Mitral regurgitation
  • Severe mitral stenosis
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2
Q

What is the S2 heart sound?

  • when may it be loud?
  • when may it be soft?
  • why would it be fixed wide splitting?
  • why would it be wide but variable splitting with delayed right heart emptying?
  • why would it be reversed splitting?
A

Aortic and pulmonary valve closure (A2 first, P2 second)

  • Occurs when ventricular pressure falls below outflow tract pressure
  • Split sounds = aortic before pulmonary
  • end of systole
  • split on inspiration, single on expiration

Split increases on inspiration due to increased venous return

A2 loud in

  • Systemic hypertension
  • Hyperdynamic circulation

A2 soft in aortic stenosis

Fixed wide splitting with atrial septal defect.

Wide but variable splitting with delayed right heart emptying (e.g. right bundle branch block).

Reversed splitting due to delayed left heart emptying (e.g. left bundle branch block)

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3
Q

Added heart sounds - S3

A

S3 (can be physiological)

Occurs in early diastole, just after S2

low pitch - often heard as ‘gallop’

From ventricular wall due to abrupt cessation of rapid ventricular filling

Normal finding in young people, or pregnancy

Represent heart failure or volume overload in older patients; mitral regurgitation

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4
Q

Added heart sounds - S4

A

S4 (always pathological)

Occurs in late diastole, just before S1
- Low pitch

Surge of ventricular filling with atrial systole - ventricular origin (stiff ventricle and augmented atrial contraction) related to atrial filling

Indicates increased ventricular stiffness e.g. hypertension, aortic stenosis or acute MI

Absent in atrial fibrillation
A feature of severe left ventricular hypertrophy (e.g. hypertrophic cardiomyopathy)

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5
Q

When might someone have a hyperdyamic circulation?

A

anaemia
pregnancy
thyrotoxicosis

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6
Q

Systolic clicks

A
  • early of mid-systole
  • brief, high intensity sound
Mechanism
- Valvular aortic stenosis
− Valvular pulmonary stenosis
− Floppy mitral valve
− Prosthetic heart sounds from opening and closing of normally functioning mechanical valves

Click may be lost when stenotic valve becomes thickened or calcified.

prosthetic clicks lost when valve obstructed by thrombus or vegetations.

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7
Q

Opening snap

A
  • early in diastole
  • high pitch, brief duration
  • Opening of stenosed leaflets of mitral valve. Prosthetic heart sounds

Moves closer to S2 as mitral stenosis becomes more severe.

May be absent in calcific mitral stenosis

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8
Q

What would you ask the patient to do to increase a right heart murmur

A

Breath in

inspiration increase right heart murmurs

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9
Q

Do benign murmurs occur in diastole?

A

NO

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10
Q

Why may a murmur not be heard?

A

HR may be too fast

- control HR then murmur will become apparent

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11
Q

What is a benign murmur?

A 
Soft
Mid-systolic
Heard at left sternal edge
No radiation 
No other cadiac abnormalities
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12
Q

How do you assess murmurs?

A 
When does it occur?
How loud is it?
Where is it heard best?
Where does it radiate?
What does it sound like?
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13
Q

How would you time a heart murmur?

A

with carotid pulse

Systolic – between S1 and S2 heart sounds

  • Aortic or pulmonary valve stenosis
  • Regurgitation of mitral and tricuspid valve

Diastolic – between S2 and S1

  • Regurgitation of aortic or pulmonary valves
  • Mitral and tricuspid valve stenosis

Continuous throughout systole and diastole.

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14
Q

What are examples of systolic murmurs? (9)

A 
Aortic stenosis
Pulmonic stenosis
Mitral regurgitation
Tricuspid regurgitation
Mitral valve prolapse
Atrial septal defect
Ventricular septal defect
Hypertrophic cardiomyopathy
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15
Q

What are examples of diastolic murmurs? (5)

A 
Aortic regurgitation 
Pulmonic regurgitation
Mitral stenosis
Tricuspid stenosis
Austin-Flint murmur
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16
Q

What are examples of continuous murmurs? (2)

A

Patent ductus arteriosus

Combination murmurs

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17
Q

Midsystolic murmur

  • when does it occur?
  • how to tell if it is ejection systolic?
  • what are they associated with?
  • what pattern will it have?
  • name 4 examples
A

Begins just after S1 and ends before P2 heart sound → S1 and S2 distinctly audible

Ejection systolic – pressure gradient varies in systole
- Hear peak halfway throughout systole. Starts quietly, ends quietly.

Associated with ventricular outflow tract obstruction

Occur in mid-systole

Crescendo-decrescendo pattern

Aortic stenosis
Pulmonic stenosis
Atrial septal defect
HOCM - hypertrophic obstructive cardiomyopathy

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18
Q

Holosystolic (pansystolic)

  • when does it occur?
  • does the intensity change?
  • name 3 examples
A

Begins with/immediately after S1 heart sound and extends up to S2 → difficult/impossible to hear

Throughout all of systole

Maintain constant intensity

Blood leaks from ventricle into low-pressure chamber at constant velocity

Mitral regurgitation
Tricuspid regurgitation
VSD

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19
Q

When does a late systolic murmur occur?

- give 1 examples

A

mid-late begins significantly after S1 and may/may not extend up to S2

Mitral valve prolapse

20
Q

Name 3 early diastolic murmurs

A

Aortic regurgitation
Pulmonic regurgitation
Austin-Flint

21
Q

Name 2 mid-late diastolic murmurs

A

Mitral stenosis

Tricuspid stenosis

22
Q

Name a rare diastolic murmur

A

Patent ductus arteriosus

23
Q

What is the grading system used for systolic murmurs?

- how would you describe each grade

A

Intensity Description

Grade 1 Barely audible

Grade 2 Audible, but soft

Grade 3 Easily audible

Grade 4 Easily audible and associated with a thrill

Grade 5 Easily audible, associated with a thrill and still heard with the stethoscope only lightly on the chest

Grade 6 Easily audible, associated with a thrill and still heard with the stethoscope off the chest

24
Q

What is the grading system used for diastolic murmurs?

- how would you describe each grade

A

Intensity Description

Grade 1 Barely audible

Grade 2 Audible, but soft

Grade 3 Easily audible

Grade 4 Loud

25
Q

Where is the best place to listen to each valve?

  • Aortic
  • Pulmonic
  • Tricuspid
  • Mitral
A

A = aortic valve post (right upper sternal border or RUSB)

P = pulmonic valve post (left upper sternal border or LUSB)

T = tricuspid valve post (left lower sternal border or LLSB)

M = mitral valve post (apex)

26
Q

Aortic stenosis

  • describe this murmur
  • where does it radiate to commonly?
  • what is a rarer place for it to radiate to? - what is the name for this?
  • is intensity a good indication of severity?
  • Can there be added heart sounds heard?
  • will findings differ in bicuspid aortic valves?
  • what are some causes?
  • how will the patient present?
  • What drug should be avoided in patients?
A

High pitched
Crescend-decrescendo
At aortic

Radiates towards neck - dont mistake for carotid bruit

Rarely - cardiac apex (Gallavardin dissociation)

Intensity not a good indicator of severity
- As AS worsens → LV begins to fail & the ejection fraction declines to the point where sufficient force to create turbulent flow is no longer produced → decrease in the intensity of the murmur.

Shape may be used to determine severity

  • Worsens – takes longer for blood to eject through valve → peak of crescendo-decrescendo moves to later in systole.
  • Mild AS – early peaking murmur
  • Severe AS – later peak in systole

Delay in aortic valve closure may cause paradoxically split S2 heart sound and as the aortic valve becomes more heavily calcified, the intensity of the S2 heart sound declines.

Patients with bicuspid aortic valves - ejection click may be heard just before murmur begins

Causes

  • Calcification of bicuspid valve
  • Rheumatic heart disease
  • Disease of aging

Presentation

  • Syncope, angina or dyspnoea
  • Low volume, slow rising pulse
  • Sustained apex beat
  • Ejection systolic murmur radiating to carotids

Severe aortic stenosis – may not be able to hear 2nd heart sound

  • Do not give vasodilator drugs (nitrates) → May cause severe syncope/dizziness
27
Q

Aortic sclerosis

  • describe this murmur
  • does it radiate?
  • how would the patient present?
A

ESM

  • Not hemodynamically significant - no gradient
  • does not radiate to carotid
  • SAD symptoms - syncope, angina, dyspnoea
28
Q

Pulmonic stenosis

A

Very similar to aortic stenosis.

  • aortic stenosis extends up to A2 heart sound
  • pulmonic stenosis extends through the A2 sound up to the P2 heart sound.
  • Severe pulmonic stenosis → decreased mobility of pulmonic valve leaflets & thus softer P2 sound.
  • As pulmonic stenosis worsens → closure of the pulmonic valve is delayed, since more time is required to eject blood through the stenotic valve, resulting in a widely split S2 heart sound that still exhibits inspiratory delay.

High-pitched
Crescendo-decrescendo

Heard best - pulmonic listening post

Radiating slightly toward neck (doesn’t radiate as widely as AS).

Severity

  • Mild – peaks early
  • Severe – peaks later

Intensity - Increases during inspiration due to increased venous return to heart (greater flow across pulmonic valve)

29
Q

Atrial septal defect

A

Due to increased flow through the pulmonic valve, thus similar to pulmonic stenosis. The difference lies in the intensity and splitting pattern of the S2 heart sound.

Intensity of S2 should remain unchanged and may be accentuated if pulmonary hypertension develops.

S2 is fixed-split

Differs from the widened split S2 seen in severe pulmonic stenosis & ASD does not increase in intensity with inspiration

30
Q

Hypertrophic obstructive cardiomyopathy (HOCM)

A

High-pitched

Crescendo-decrescendo

Mid systolic murmur

Heard best at the left lower sternal border

Does not radiate to the carotids like that of AS.

Differentiate from AS – dynamic auscultation

31
Q

Mitral regurgitation (MR)

A 
•	High-pitched
•	"Blowing" 
•	Best heard at apex
•	Direction of radiation depends on nature of mitral valve disease - usually radiates to axilla. 
•	Intensity does not increase with inspiration  - distinguish from tricuspid regurgitation.
•	Blood leaking back into right atrium
•	Causes:
o	Rheumatic heart disease
o	LV dilatation (e.g. after extensive MI)
o	Degeneration
•	Endocarditis
•	Ruptured chordae
•	Ruptured papillary muscle
•	Floppy mitral valve/ prolapse
•	Presentation
o	Sinus rhythm or AF
o	Hyperdynamic, displaced apex
o	Systolic thrill
o	Soft S1
o	Pan-systolic murmur at apex radiating to axilla 
•	Causes of acute presentation
o	Papillary rupture
o	Acute endocarditis
o	Rupture of chordae tendonae
o	No time for ventricle to enlarge and compensate → straight into pulmonary oedema
32
Q

Tricuspid regurgitation

A

Similar to mitral regurgitation
• High pitched
• Best heard at left lower sternal border
• Radiates to the right lower sternal border
• Intensity significantly increases with inspiration (“Carvallo’s sign”)
o Helps to distinguish from mitral regurgitation

33
Q

Ventricular septal defect (VSD)

A

Blood abnormally flows from the LV (high pressure) to the RV (low pressure) → turbulent blood flow
• Heard best at “Erb’s point”
• The smaller the ventricular septal defect, the louder the murmur – loud murmur means small VSD
• Congenital or acquired (e.g. post-MI)
• DD: acute mitral regurgitiation

34
Q

Mitral valve prolapse (MVP)

A
  • Mid-systolic click usually followed by a uniform, high-pitched murmur
  • Due to mitral regurgitation that accompanies the mitral valve prolapse - thus heard best at cardiac apex.
  • Mitral valve prolapse responds to dynamic auscultation.
  • Mitral regurgitation confined to late systole
  • Hypertrophic obstructive cardiomyopathy if dynamic obstruction occurs late in systole
35
Q

What should you consider in early diastolic murmurs?

A

Aortic and pulmonic regurgitation

36
Q

What should you consider in mid-late diastolic murmurs?

A

Mitral or tricuspid stenosis

37
Q

Aortic regurgitation (AR)

A 
•	Soft 
•	High-pitched
•	Early diastolic 
•	Decrescendo 
•	Heard best at the 3rd intercostal space on the left (Erb's point) at end expiration with patient sitting up and leaning forward. 
•	If due to aortic root disease - best heard at the right upper sternal border (not Erb's point) 
•	As worsens in severity - pressure between left ventricle and aorta equalize much faster → murmur becomes significantly shorter.
•	Early diastolic rumble may be heard at apex due to the regurgitant jet striking the anterior leaflet of the mitral valve causing it to vibrate – known as Austin-Flint murmur.
•	A systolic ejection murmur may be present in people with severe aortic regurgitation at the right upper sternal border due to the large stroke volume passing through the aortic valve with each systolic contraction of the LV.
•	Causes
o	Rheumatic heart disease
o	Infective endocarditis
o	Bicuspid aortic valve
o	Rarer:
•	Dissection of aorta
•	LV dilatation
•	Syphilis / arthritides
•	Marfan’s syndrome
•	Presentation
o	Left ventricular failure
o	Hyperdynamic circulation
o	Collapsing pulse
o	Thrusting and laterally placed apex
o	High pitched early diastolic murmur at left sternal edge (4th IS), leaning forward in full expiration
38
Q

Pulmonic regurgitation (PR)

A 
•	"Graham-Steell murmur"
•	Often indistinguishable from aortic regurgitation
•	Soft
•	High-pitched
•	Early diastolic
•	Decrescendo 
•	Heard best at the pulmonic listening post (LUSB)
•	Intensity increases during inspiration
o	Unlike that of aortic regurgitation.
39
Q

Mitral stenosis

A

• Low-pitched
• Best heard at the cardiac apex.
• Opening of the mitral valve produces an “opening snap” due to the high left atrial pressures, which is immediately followed by a decrescendo murmur as blood flows passively from the left atrium to the left ventricle through the stenosed mitral valve creating turbulence.
• Immediately before the S1 sound, active left ventricular filling occurs when the left atrium contracts and forces more blood through the stenosed mitral valve creating a late diastolic crescendo murmur. In the presence of atrial fibrillation, the active left ventricular filling phase does not take place and the latter part of the mitral stenosis murmur disappears.
• As mitral stenosis worsens, left atrial pressure increases forcing the mitral valve open earlier in diastole.
o Severe mitral stenosis - the opening snap occurs earlier as does the initial decrescendo part of the murmur.
• The opening snap and murmur of mitral stenosis also respond to dynamic auscultation.
• Most common cause = rheumatic heart disease
• Leads to valve thickening
o Cusp fusion
o Calcium deposition
o Progressive immobility of valve cusps
• Presentation
o Mitral flush
o AF
o Parasternal heave
o Loud S1 (not if calcific and non-pliable cusps)
o Opening snap
o Mid-diastolic rumble at apex

40
Q

Valsalva maneuver

A

• Performed by having a patient “bear down” like they are going to have a bowel movement and exhaling forcefully with the airway closed
• Causes decrease in left ventricular preload
• Used to distinguish the murmur of aortic stenosis from hypertrophic obstructive cardiomyopathy (HOCM) or simply to bring for the murmur of HOCM.
o Aortic stenosis will soften or not change
o HOCM becomes quite loud
• Also performed during routine echocardiographic examinations to see if patients with grade II or worse diastolic function can decrease their left ventricular filling pressures adequately.
o If the Valsalva maneuver fails to reduce the left ventricular pressure in the setting of diastolic heart failure, then grade IV diastolic dysfunction is said to be present which indicates a poor prognosis.

41
Q

Squatting from a standing position

A
  • Squatting forces the blood volume that was stored in the legs to return to the heart increasing preload and thus increasing left ventricular filling.
  • Will decrease the murmur of hypertrophic obstructive cardiomyopathy as the increased left ventricular volume helps displace the hypertrophied interventricular septum causing less outflow tract obstruction.
  • Causes the click of mitral valve prolapse to move later in systole.
42
Q

Standing from a squatting position

A

• Causes blood to move from the central body to the legs resulting in less blood returning to the heart decreasing left ventricular preload similar to that seen with the Valsalva maneuver.
• Will:
o Increase the murmur of hypertrophic obstructive cardiomyopathy
o Decrease that of aortic stenosis.
• Causes the click of mitral valve prolapse to move earlier in systole.

43
Q

Leg raising

A
  • Passive leg raising is permed simply by raising the legs high in a patient lying supine.
  • Results in blood that was pooled in the legs returning to the heart increase left ventricular filling and preload similar to squatting from a standing position.
  • Will decrease the murmur of hypertrophic obstructive cardiomyopathy as the increased left ventricular volume helps displace the hypertrophied interventricular septum causing less outflow tract obstruction.
  • Causes the click of mitral valve prolapse to move later in systole
44
Q

Handgrip exercise

A
  • Isometric handgrip exercises are performed by having a patient squeeze hart repetitively.
  • Results in increased blood pressure (similar to exercise) and thus increased afterload.
  • Elderly individuals may have a hard time with this maneuver and thus transient arterial occlusion can be used instead.
  • Will increase the intensity of left-sided regurgitant murmurs including mitral regurgitation and aortic regurgitation.
  • Will have no effect on the murmur of aortic stenosis which helps distinguish the presence of coexistent mitral regurgitation from that of the Galliveridin phenomenon.
45
Q

Transient arterial occlusion

A
  • Performed by placing a blood pressure cuff on both arms and inflating it to 20 to 40 mmHg above the systolic blood pressure for 20 seconds → increases afterload.
  • Will increase the intensity of left-sided regurgitant murmurs including mitral regurgitation and aortic regurgitation
  • Especially useful in elderly individuals who are not able to perform adequate handgrip exercises.
46
Q

Amyl nitrate inhalation

A

Amyl nitrate decreases left ventricular afterload by dilating the peripheral arteries. and would decrease the murmur of mitral regurgitation.
• When the afterload is decreased, there is less resistance to blood flow from the left ventricle through the aortic valve and thus less blood regurgitates through the mitral valve, decreasing the intensity of the murmur.
• Amyl nitrate can be given via inhalation to reduce afterload for diagnostic purposes in the cardiac catheterization laboratory (to invoke a LV outflow tract gradient in hypertrophic obstructive cardiomyopathy patients) or as a diagnostic tool during cardiac physical examination. Due to the advancement of echocardiography, it is not commonly used any longer.

Cardiology (7 decks)

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