Murmurs Flashcards
What do S1 and S2 represent?
S1 - closure of mitral and tricuspid valves
between S1 and S2 = SYSTOLE
S2 - closure of aortic and pulmonic valves
between S2 and next S1 = DIASTOLE
What are the 4 anatomical auscultation sites?
- Aortic = 2nd ICS RUSB
- Pulmonic = 2nd ICS LUSB
- Tricuspic = 4th ICS
- Mitral = 5th ICS MCL (apex)
(erb’s point - 3rd ICS LSB = best point for auscultation of murmurs)
Aortic Stenosis - main facts
- ventricles contract against partially closed aortic valve
- murmur starts a few milliseconds into systole when the valve snaps open producing a systolic murmur with an EJECTION CLICK
- crescendo-decrescendo murmur (diamond shaped)
- radiates to the neck/carotids (as these are some of the first branches of the aorta)
Aortic Stenosis - clinical features
Aortic stenosis
Syncope
Angina
Dyspnoea
High and low (crescendo-descrescendo)
Ejection click
Age (main cause - degenerative calcification)
Radiates to carotids
Take out (replace) or repair (valvuloplasty)
•chest pain
•dyspnoea
•exertional syncope
(SAD = syncope, angina, dyspnea)
Severe AS
- narrow pulse pressure
- slow rising pulse
- soft or absent S2
- S4
- thrill
- LVH or failure
Causes of aortic stenosis
- degenerative calcification (most common cause in older patients > 65 years)
- bicuspid aortic valve (most common cause in younger patients < 65 years)
- post-rheumatic disease
- subvalvular: HOCM
Aortic Stenosis - management
- if asymptomatic then observe the patient is general rule - echo follow up etc.
- if symptomatic and stable –> aortic valve replacement (either open surgery or transcatheter)
- clinically unstable or unfit for replacement –> balloon valvuloplasty = percutaneous procedure - balloon is forcefully inflated across aortic valve to relieve stenosis
What other medical management must be offered post valve replacement?
- long-term infective endocarditis antibiotic prophylaxis
- long-term anticoagulation - indicated in those patients who have had aortic valve replacement using prosthetic mechanical valves.
Pulmonic stenosis?
- same idea as AS –> systolic crescendo-decrescendo murmur with ejection click
- however best heard on pulmonic valve area and does not radiate to carotids
Causes of ejection systolic murmur
- aortic stenosis
- pulmonary stenosis, hypertrophic obstructive cardiomyopathy
- atrial septal defect, tetralogy of Fallot
Mitral regurgitation - main facts
MVP, post-MI (causes) Insufficiency of heart (leads to HF) Treat HF symptoms Radiates to axilla All of systole (holosystolic) Lelf atrial dilatation Repair over replacement (usually)
- holo/pan systolic
- “flat murmur” - same pitch throughout systole bc in chronic MR the atrium expands during systole to become more compliant
- radiates to axilla (blood flow going back up)
- S1 may be quiet as a result of incomplete closure
- Severe MR may cause a widely split S2
S1 —Brrrrrr— S2
What is the main complication as MR progresses?
As the degree of regurgitation becomes more severe, the body’s oxygen demands may exceed what the heart can supply and as a result, the myocardium can thicken over time. While this may be benign initially, patients may find themselves increasingly fatigued as a thicker myometrium becomes less efficient, and eventually go into irreversible heart failure.
- can lead to S3
Mitral regurgitation - causes
- Age-related
- Following coronary artery disease or post-MI: if the papillary muscles or chordae tendinae are affected by a cardiac insult, mitral valve disease may ensue
- Mitral valve prolapse
- Infective endocarditis: vegetations from the organisms colonising the valve prevent it from closing properly
- Rheumatic fever
- Congenital
MR - symptoms
- Most patients with MR are asymptomatic
- Symptoms tend to be due to failure of the left ventricle, arrhythmias or pulmonary hypertension
- This may present as fatigue, shortness of breath and oedema.
MR - investigations
- ECG may show a broad P wave, indicative of atrial enlargement
- Cardiomegaly may be seen on chest x-ray, with an enlarged left atrium and ventricle
- Echocardiography is crucial to diagnosis and to assess severity
MR - management
- Medical management in acute cases involves nitrates, diuretics, positive inotropes and an intra-aortic balloon pump to increase cardiac output
- If patients are in heart failure, ACE inhibitors may be considered along with beta-blockers and spironolactone
- In acute, severe regurgitation, surgery is indicated –> balloon valvuloplasty, annuloplasty (tighten ring) or vavle replacement
- The evidence for repair over replacement is strong in degenerative regurgitation, and is demonstrated through lower mortality and higher survival rates
- When this is not possible, valve replacement with either an artificial valve or a pig valve is considered
Tricuspid regurgitation?
- holosystolic, flat murmur
- but heard on tricuspid area and does not radiate to axilla
Causes of holosystolic murmur?
Holosystolic (pansystolic)
•mitral/tricuspid regurgitation (high-pitched and ‘blowing’ in character)
•ventricular septal defect (‘harsh’ in character)
Mitral valve prolapse
- patients may complain of atypical chest pain or palpitations
- mid-systolic click (occurs later if patient squatting) - as LV begins to contract, valve closes (S1) but then snaps back due to rapid tensing of cordae tendinae
- late systolic murmur (longer if patient standing)
- heard on apex (mitral area)
- complications: mitral regurgitation, arrhythmias (including long QT), emboli, sudden death
MVP - associations
- congenital heart disease: PDA, ASD
- cardiomyopathy
- Turner’s syndrome
- Marfan’s syndrome, Fragile X
- Wolff-Parkinson White syndrome
- long-QT syndrome
- Ehlers-Danlos Syndrome
- polycystic kidney disease
Late systolic murmur - causes
Late systolic
•mitral valve prolapse
•coarctation of aorta
Aortic Regurgitation - features
AR ACHES Age related (most commonly) Collapsing pulse Heart Failure Early diastolic decrescendo Sign: Quincke's
- early diastolic murmur - decrescendo
- best heard on left sternal border
- collapsing pulse (corrigan sign or Watson’s water hammer pulse)
- wide pulse pressure
- Quinke’s sign (nailbed pulsation on light compression)
- De Musset’s sign (head bobbing)
- can also lead to HF
AR - causes
- idiopathic age related
- rheumatic fever
- infective endocarditis
- connective tissue diseases e.g. RA/SLE
- bicuspid aortic valve
- aortic dissection
- spondylarthropathies (e.g. ankylosing spondylitis)
- hypertension
- syphilis
- Marfan’s, Ehler-Danlos syndrome
AR - treatment
- inotropes e.g. dopamine
- vasodilators e.g. nifedipine or hydralazine
- aortic valve replacement or repair (transcatheter aortic valve implantation )
Mitral Stenosis - features
Mid diastolic Infective endocarditis, rheumatic fever (causes) Tapping apex beat Rumbling sound Atrial fibrillation Left atrium enlargement S1 loud
• mid-late diastolic murmur (best heard in expiration)
• loud S1 (loud closure of valve) + opening snap due to “rapid filling” against the stenosed valve - can palpate ‘tapping’ apex beat
• Opening snap is followed by a mid diastolic rumble
Best heard with pt on left lateral decubitus
• low volume pulse
• malar flush (backup pulm pressure causes raised Co2 and vasodilation)
• atrial fibrillation
Complications = left atrial enlargement, pulmonary hypertension
LUB. DUH drrrrrrrr
LUB (loud S1) —systole—-DUH (opens mid diastole) - Drrrrrrr (diastolic rumble)
What is by far the most common cause of MS?
Rheumatic Fever
2nd is infective endocarditis
MS - investigations
Chest x-ray
•left atrial enlargement may be seen (eg. double right heart border)
Echocardiography
•the 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
Mitral Stenosis - management
- asymptomatic –> no therapy required
- symptomatic or presence of pulmonary hypertension –> balloon valvotomy
- severe symptomatic –> diuretics (reduce left atrial pressure) + balloon valvotomy/ valve replacement or repair
What are the extra heart sounds?
- S3 (ventricular gallop)
- S4 (atrial gallop)
- heard best on left lateral decubitus position
What is S3?
Ventricular Gallop
- volume overload condition
- early diastole during rapid filling phase
- extra volume overstretches ventricle and causes tensing of cordae tendinae leading to S3
- normal in kids/adolescents
- abnormal in older people eg. CHF, dilated cardiomyopathy, constrictive pericarditis, MR
What is S4
Atrial Gallop
- pressure overload problem, when heart needs to contract against increased pressure (e.g. hypertension) this leads to myocardial hypertrophy (concentric, so ventricular volume decreases)
- S4 thus results from atrium contracting against a stiff ventricle
- “get that last bit of blood out” –> end of diastole
- always pathological - AS, hypertension, HOCM (double apical impulse may be felt - palpable S4)
Valve related Hypertrophy and Dilatation
Hypertrophy
- happens to chamber behind stenosis (pushing harder to get blood through)
- e.g. AS would lead to LVH
Dilatation
- happens to chamber behind regurgitation (as blood flowing back stretches the muscle)
- e.g. MR would lead to left atrial dilatation
JVP
Causes of raised JVP: HF, fluid overload, constrictive pericarditis, cardiac tamponade, pulm htn, SVCO, TR/TS
JVP Waves A : Atrial contraction X : relaX C : Closure (of tricuspic valve) V : Volume (atrial filling) Y : the blood goes awaY
absent A wave = atrial fibrillation
large A wave = RVH or tricuspid stenosis
large V wave = tricuspid regurgitation, pulm htn
