Murmurs

Question 1

normal heart sounds

Answer 1

lub dub, lub dub
sounds of the valve closing projected on the chest wall

S1: tricuspid and mitral valve closing (AV valves)

S2: aortic and pulmonary valves closing (semilunar valves)

Question 2

stages of the cardiad cycle

Answer 2

1. late diastole: both chambers are relaxed and blood fills passively from A to V. The AV valves (M and T are open)
2. Atrial systole
   SA to AV node fires. Atria contraction. Forces the final amount of blood into the ventricles.
3. S1= AV valves M/T close (lub) to stop blood going from V (high pressure) back to A (lower pressure)
4. Isovolumetric contraction
   volume stays the same (same amount of blood)
   but pressure increases in V.
   *AV are closed
   *Semilunar valves are closed (pulmonary artery and aorta still higher pressure)
5. Ventricular ejection
   Ventricles contract and exceed the pressure of pulmonary arteries and aorta. the semilunar valves open and blood is ejected.
6. Isovolumetric relaxation
   Ventricles relax (diasotle)
   P/A is now higher than the ventricles so the semilunar valves snap shut (to prevent blood from moving from high PA to low V)
   *S2 semilunar valves shut (dub)
7. Early diastole
   Pressure in Atria now exceeds the Ventricles so the AV valves open. A is receiving blood, passive filling.

Question 3

S1
S2
S3

Answer 3

S1: AV valves closing
S2: Semilunar valves closing
S3: blood filling from A to V in early diastole. if there is a lot of blood (HF) can bounce on the walls and cause a third heart sound. / rapid ventricular filling causes the coordinate tendinae to pull on their full length and twang (pregnancy, athletes, heart failure, LV failure

Diastole [S1] systole [S2}

Question 4

definition of a murmur

Answer 4

turbulent blood flow

graded from 1-6

Question 5

Systolic murmur

Answer 5

happens between S1 and S2 (S1 woooosh S2)

in systole, the M/T are closed and SL is open.

mitral / tricuspid valve cannot close (regurgitation)

aortic / pulmonary valve cannot open (stenosis)

Question 6

Diastolic murmur

Answer 6

happens after S2 (S1, S2, wooosh, S1, S2)

M/T are open
SL are closed

mitral/tricuspid cannot open (stenosis)

aortic/pulmonary cannot close (regurgitation)

Question 7

Mitral regurgitation

Answer 7

• systolic murmur
• ventricules are at a higher pressure than atria so M/T is shut (S1) to prevent blood flowing back to lower pressure in atria.
• if the M/T cannot close properly, the blood will continue to flow throughout systole into the atria
• heard best with bell of stethoscope over the apex, pt lying on the left lateral position

early opening snap suggests severe mitral stenosis (and a quiet S1)

= pansystolic / holosystolic murmur (i.e throughout systole)

dilated cardiomyopathy left ventricular dilation results in mitral regurgitation.

Question 8

Tricuspid regurgitation

Answer 8

• systolic murmur
• pansystolic murmur
• can be heard 4-5th rib lower left border of the STERNUM

Question 9

Aortic stenosis

Answer 9

*systolic murmur

the aorta/pulmonary valves cannot open (stenosis) so blood has to flow through a narrow opening from V to PA. at the beginning of systole there is a lot of blood trying to get through. this get’s quieter as blood passes and eventually the valves ‘snap’ open (ejection click)

= crescendo decrescendo murmur

• classically radiates to the carotids
• peripheral pulses are weak and delayed.
• aortic stenosis 2-3rd IC space right
• pulmonary stenosis 2-3rd IC left.

Question 10

Carvello sign

Answer 10

tricuspid regurgitation is louder on inhalation. This is because the negative pressure (diaphragm goes down) means more blood goes back to RA so more blood is rushing into RA (tricuspid is R)

Question 11

Aortic valve regurgitation

Answer 11

diastolic murmur

In diastole, the semilunar valves are shut because PA is higher pressure than V. blood leaks from aorta back to LV (loud, lots of blood then quietens)

= early diastolic decrescendo (high pitched blowing diastolic decrescendo murmur)

Question 12

murmurs in summary

Answer 12

1. systolic murmurs
   - mitral regurgitation (pan systolic murmur)
   - aortic stenosis (ejection click, crescendo decrescendo murmur)
2. diastolic murmur
   - mitral stenosis (diastolic rumble)
   - aortic regurgitation (early diastolic decrescendo)

Question 13

S4 heart sound

Answer 13

in late diastole (atrial systole) the atrias contract and push the final amount of blood into the ventricles.

if the ventricles are very stiff, the atria has to push extra hard to push blood from A to V (e.g. in ventricular hypertrophy) this makes a fourth heart sounds

Question 14

innocent murmurs (still’s murmurs)

Answer 14

heart walls are very thin- they vibrate when blood rushes (disappears with young age)

still’s murmur is heard over the left lower sternal border (common in young children)

Question 15

mitral valve prolapse

Answer 15

the valves fall back into the atrium- papillary muscles and chordae tendinae are too weak to keep tethered.

mid systolic click- leaflet folds into atrium then stopped suddenly by chordae tendinae

mid systolic click followed by a late systolic murmur ?

Question 16

mitral regurgitation and squatting / valsalva

Answer 16

If squat down- click comes later and murmur shorter. Squatting increase venous return so more LV in blood so more volume so there is more room for the leaflets and so they get forced back into the atrium a bit later

If stand/Valsalva- click comes sooner and murmur logger. Standing- less venous return- ventricle is smaller so the leaflet is forced out earlier in the contraction (why it’s longer)

Question 17

Austin flint murmur

Answer 17

aortic regurgitation is so severe a jet blood forces the mitral valve shut which causes a rumbling mid diastolic murmur in mitral valve area with out opening snap sound

Question 18

VSD

Answer 18

pan systolic murmur

*

Question 19

RBBB

Answer 19

white split of second heart sound

Question 20

ASD

Answer 20

ejection systolic murmur associated with split second heart sound over the pulmonary area (usually congenital)

Question 21

Tricuspid regurgitation and heart failure

Answer 21

back flow of blood from RV to RA. This causes the right side of the heart to dilate and weaken. Back pressure on the IVC and poor ejection fraction

oedema, ascites, dyspnoea (HF)

Question 22

murmur from chronic rheumatic fever

Answer 22

mitral stenosis (60%)
aortic stenosis (30%)

opening snap after S2, followed by a rumbling mid-diastolic murmur.

Question 23

Jones’ criteria

Answer 23

chronic rheumatic heart disease from previous untreated pharyngitis caused by a group A beta-haemolytic streptococcal infection.

+ evidence of previous sterptococcal infection
+ two or more of the following major Jones’ criteria

1. migratory polyarthritis of large joints
2. carditis
3. subcutaenous nodules
4. chorea
5. erythma marinatum of the skin

or a diagnosis can be made with 1 from major and 2 from minor:
fever, arthralgia, elevated acute phase reactants

Question 24

Patent ductus arteriousus

Answer 24

a continuous machine like murmur loudest at S2

Question 25

pericarditis

Answer 25

fever, upper resp infection, pleuritic chest pain, ST elevation, PR depression on ECG

aggravated by movements / deep inspiration, non-radiating. improves when leaning forward

pericardial friction rub (scratchy, rubbing quality)

high pitched triphasic systolic and diastolic murmur

Question 26

aortic stenosis and agina

Answer 26

angina can be a presenting feature of aortic stenosis.

angina- exertional chest pain and slow rising pulse

Question 27

intra-cardiac tumour

Answer 27

atrial myxoma
fragments of the tumour break off and embolus into the cerebral arteries causing a TIA

murmur: atrial plop in early diastole

Question 28

Infective endocarditis clinical features and murmur heard

Answer 28

constitutional upset- fever, night sweats, malaise, exertion dyspnoea, splinter haemorrhages and visible capillary pulsations in the nail bed (Quincke’s sign)

aortic regurgitation 2’ to infective endocarditis

Question 29

coarctation of the aorta

Answer 29

hypertension in the upper extremities, hypotension in the lower extremities

long term hx of hypertension
painful, burning sensation in both legs

aortic lumen narrows distal to the arch vessels

CXR notching of the ribs.

Question 30

bicuspid aortic valve without calcification

Answer 30

one of the most common congenital heart malformations in adults

early systolic ejection click

some degree of AR or AS
blowing early diastolic murmur and or systolic ejection murmur

susceptible to calcification and fibrosis

Question 31

management for an MI

Answer 31

High Flow O2 (15L/min)
Aspirin & Clopidogrel
GTN Spray
Morphine
Beta Blocker

Question 32

infective endocarditis symptoms

Answer 32

Splinter Haemorrhages/ Osler Nodes/ Janeway lesions

Question 33

hypertrophic cardiomyopathy

Answer 33

hypertrophic obstructive cardiomyopathy / assymetric septal hypertrophy / idiopathic hypertrophic subaortic stenosis

inherited autosomal dominant
common cause of sudden death in young atheltes

Question 34

endocarditis

Answer 34

streptococcus aureus is the most common cause of endocarditis (prosthetic valve replacement, IV drug use)

streptococcus viridians is more common after dental extraction.

endocarditis is an infection on a calcified aortic valve

Question 35

multiple pulmonary emboli

Answer 35

evidence of right ventricular hypertrophy and pulmonary hypertension (loud P2)

collapse and reduced exercise capacity.

underlying cancer DVT

diagnose with CT and pulmonary angiogram

Question 36

aortic stenosis

Answer 36

congenital bicuspid valve
rheumatic fever

slow rising pulse
narrow pulse pressure
non-displaced heaving apex bet
ejection systolic murmur that radiates to the carotids
symptoms of LV dysfunction and outflow tract obstruction

investigate:
CXR, ECG, echo, cardiac catheter studies

Mx: aortic valve replacement
if inoperable- diuretic therapy