Murmurs Flashcards
What is heart sound 1
closing of the atrioventricular valves (the tricuspid and mitral valves) at the start of the systolic contraction of the ventricles
What is heart sound 2
closing or the semilunar valves (the pulmonary and aortic valves) once the systolic contraction is complete.
What causes a third heart sound
- the ‘twanging’ on chordae tendonae once pulled to their full length during refilling
- can be normal in young people ( vent. fill rapidly)
- Can occur in HF the ventricles (chordae are stiff)
What is a fourth heart sound
- Hear directly before S1, always abnormal and rare to hear
- indicates a stiff or hypertrophic ventricle
Where is the best place to listen for heart sounds 1 + 2
Erb’s point: third intercostal space on the left sternal boarder
What special manouvre do you do to best hear mitral stenosis
Patient on their left side
What special manouvre do you do to best hear aortic regurgitation
Patient sat up, learning forward and holding exhalation
How to present a murmur
- The patient has a ……….., sys/dia murmur
- heard best over the …….. area
- that does/does not radiate to ……..
- It is high/low pitched
- cresendo/decrescendo shape
- Mostly suggestive of …….
What can valvular heart disease lead to
hypertrophy - stenosis
dilatation - regurgitation
What does mitral stenosis do to the heart muscle
left atrial hypertrophy
What does aortic stenosis do to the heat muscle
left ventricular hypertrophy
What does Mitral regurgitation do to the heat muscle
left atrial dilatation
What does aortic regurgitation do to the heat muscle
left ventricular dilatation
What is mitral stenosis
narrow mitral valve making it difficult for the left atrium to push blood through to the ventricle.
What are the main causes of mitral stenosis
Rheumatic Heart Disease
Infective Endocarditis
What murmur would you expect to hear in mitral stenosis
- mid-diastolic, low pitched “rumbling” murmur
- Loud S1
What is associated with mitral stenosis
- Mallor Flush
- AF
How is a mallor flush caused
back-pressure of blood into the pulmonary system causing a rise in CO2 and vasodilation.
Why does mitral stenosis lead to AF
left atrium struggling to push blood through the stenotic valve causing strain, electrical disruption and resulting fibrillation.
What is mitral regurgitation
- incompetent mitral valve allows blood to lead back through during systolic contraction of the left ventricle.
What is the end result of mitral regurgitation
Congestive cardiac failure: the leaking valve causes a reduced ejection fraction and a backlog of blood that is waiting to be pumped through the left side of the heart
What type of murmur would you expect to hear in mitral regurgitation
- pan-systolic, high pitched “whistling” murmur
- radiation to left axilla
- +/- third heart sound.
What are the chronic causes of Mitral regurgitation
- Myxomatous degeneration: elastic becomes floppy
- Functional with LV failure
- Connective tissue disorders e.g. Ehlers danlos
What is aortic stenosis
Most common valvular disease narrowing of the aortic valve which restrict blood flow from the left ventricle to the rest of the body
What type of murmur would you hear with aortic stenosis
- ejection-systolic, high pitched murmur
- crescendo - decrescendo
- radiates to carotid
- Slow rising pulse and narrow pulse pressure
What are the causes of aortic stenosis
- idiopathic age related calcification
- Rheumatic heart disease
What is aortic regurgitation
Aortic regurgitation is leakage of the aortic valve each time the left ventricle relaxes leading to blood to flow in two directions.
What would you expect to hear in aortic regurgitation
- DIFFICULT TO HEAR!
- early diastolic, soft murmur
- corrigans Pulse
What is the end result of aortic regurgitation
HF due to a back pressure of blood waiting to get through the left side of the heart.
What is an Austin Flint murmur
heard at the apex and is an early diastolic “rumbling” murmur. This is caused by blood flowing back through the aortic valve and over the mitral valve causing it to vibrate as a result of aortic regurgitation
What are the causes of aortic regurgitation
- Idiopathic age related weakness
- Connective tissue disorders such as Ehlers Danlos syndrome or Marfan syndrome
Where do people tend to have scars during valve replacements
- midline sternotomy scar: mitral or aortic valve replacement or CABG
- lateral thoracotomy: mitral valve replacement
What are the two types of valves used in repalcement
- Bio-prosthetic valves: pig/cow, 10 year lifespan.
- Mechanical: 20 year span but require lifelong anti-coag
What is the target INR in someone with a mechanical heart valve
2.5-3.5
What are the major complications of mechanical heart valves
- Thrombus formation
- Infective endocarditis
- Haemolysis causing anaemia (blood gets churned up in the valve)
When do you hear clicking in valve replacement
S1: mitral valve
S2: aortic valve
What is the incidence of Infective endocarditis in patients with valve replacement
2.5% with a mortality of 15%
What are the most common pathogens causing infective endocarditis
Gram positive cocci organisms:
- Staphylococcus
- Streptococcus
- Enterococcus
Causes of Aortic regurgitiation
R: Rheumatic E: Endocarditis A: Ank spond L: leutic heart disease: syhpillus M: marfans
What are the symptoms of aortic stenosis
S: Syncope
A: Angina
L: left-ventricular failure
S: Sudden death
What is the difference between aortic stenosis and aortic sclerosis
In sclerosis:
- no radiation to the carotids
- apex beat is not displaced
- No signs of heart failure
Features of aortic stenosis except the murmur
- Radiation tot he carotid
- Slow-rising pulse
- Narrow pulse pressure
- Heaving apex beat
3 murmurs more likely to see in OSCEs
- Aortic sclerosis
- Aortic stenosis
- Mitral regurgitation
What are the indications for surgery for aortic stenosis
- Symptomatic
- CCF
- Concamitant CABG
- Mean transvalvular p. gradient >40
- valve are <1cm
- Jet velocity >4m/s
What may a sternotomy scar represent
- CABG: look at saphenous vein
- Valve replacement
What is the presentation of a patient with a tissue valve replacement
- midline sternotomy scar
- normal pulse
- no murmur
- Normal HS
- No scars on legs
- No signs of heart failure
What are the differential diagnoses of midline sternotomy without leg scar
- tissue valve replacement
- metallic valve replacement
- CABG using internal thoracic vein
- Congenital cardiac disease repair
How can you do a valve replacement
- midline sternotomy
- Transcatheter aortic valve implantation
What are the key features of a metallic heart valve
- Clicks
- Lifelong warfarinisation
- last 20 years
- If you hear a regurgitant murmur, likely failing (small flow murmur is ok)
What are the key features of a tissue heart valve
- no additional noises
- A small regurgitant murmur is ok
- Lasts 10 years
- Doesn’‘t need lifelong warfarin
- Aortic: aspirin only
- Mitral: 3 months warfarin then aspirin
What is the target INR during the 3 month period of a tissue mitral valve replacement
2-3 (2.5)
What is the target INR for an aortic mechanical valve
2.5-3.5 (3)
What is the target INR for an mitral mechanical valve
3-4 (3.5)
- High risk of thromboembolic events
What are the acute causes of mitral regurgitation
- Infective endocarditis
- Papillary muscle rupture following inferior or posterior MI
- Rheumatic Heart Disease
What other signs may you see with mitral regurgitation
- Undisplaced apex
- Axillary radiation
- Fine bibasal crackles
- Oedema to mid thigh
- CCF (Both RVF and LVF)
