Murmurs

Question 1

Which murmurs are increased with inspiration

Answer 1

Right sided

Question 2

Which murmurs are increased with expiration

Answer 2

Left sided

Question 3

Systolic murmurs

Answer 3

Aortic stenosis
Mitral regurgitation
Tricuspid regurgitation

Question 4

Diastolic murmurs

Answer 4

Aortic regurgitation

Mitral stenosis

Question 5

Aortic stenosis on auscultation

Answer 5

Crescendo decrescendo systolic ejection murmur - exaggerated by sitting forward

Radiates to carotids

Soft S2 in very severe cases

Question 6

Presentation of aortic stenosis

Answer 6

SAD:
Syncope
Angina
Dyspnoea

Dizziness 
Decreased pulse rate - slow rising pulse 
Aortic thrill
Murmur 
Hypotension

Question 7

Causes of aortic stenosis

Answer 7

Age related degeneration/ calcification
Congenital bicuspid valve - ejection click
Rheumatic fever - commiserate fusion

Question 8

Consequences of aortic stenosis

Answer 8

• Increased end systolic volume causing LV hypertrophy causing LVHF
• microangiopathic haemolytic anaemia
• dizziness/LOC causing falls

Question 9

Causes of aortic regurgitation

Answer 9

BEAR: 
Bicuspid aortic valve 
Endocarditis -Pupillary muscle or chordae tendinae degeneration 
Aortic root dilation 
Rheumatic fever 

Other:
Marfans syndrome
Type A aortic dissection

Question 10

Consequences of aortic regurgitation

Answer 10

Increased end systolic volume causing LV hypertrophy - LVHF

Increased systolic pressure and decreased end diastolic pressure - increased pulse pressure

Question 11

Signs of aortic regurgitation

Answer 11

• Early decrescendo murmur - ejection systolic murmur
• Corrigan’s pulse - Collapsing pulse
• De musset’s sign - - bobbing head
• quinke’s sign - capillary pulsation in nail bed
• water hammer pulse - hyperdynamic

LVF:
Exertional dyspnoea
PND
Orthopnoea
Angina

Question 12

Causes of mitral regurgitation

Answer 12

Myxomatous degeneration 
Post MI pupillary muscle damage 
LVHF - left ventricular dilatation stretches valve 
Rheumatic heart failure
Marfans

Question 13

Mitral regurgitation murmur

Answer 13

Holosystolic or pansystolic
Loudest at apex
Radiates to axilla

Question 14

Causes of mitral stenosis

Answer 14

Rheumatic fever - commisural fusion of leaflets

Question 15

Consequences of mitral stenosis

Answer 15

Left atrium dilation - compresses oesophagus causing dysphagia 
AF - can cause thrombus formation 
Pulmonary oedema - dyspnoea 
Pulmonary hypertension 
RV hypertrophy - RVHF

Question 16

Mitral stenosis murmur

Answer 16

Diastolic rumble

Question 17

Ortner syndrome

Answer 17

Hoarseness of voice due to compression of recurrent laryngeal nerve and dysphagia

Question 18

Causes of tricuspid regurgitation

Answer 18

Right ventricular dilatation due to RVHF
IVDU
Rheumatic fever
Infective endocarditis

Question 19

Which organisms causing IE commonly affect the tricuspid valve?

Answer 19

Staph aureus
Pseudomonas
Candida

Question 20

Relevant Investigations

Answer 20

Observations
Bloods - FBC, U+Es, LFTs, CRP - rheumatic fever
ECG
Echocardiogram

Question 21

Management of aortic stenosis

Answer 21

1. Minimise RF
   - statins
   - anti hypertensives
   - diabetes control
2. Regular follow ups with echocardiogram
3. If angina - beta blocker (avoid nitrates)
4. If HF - furosemide and ACEi
5. Surgery

Question 22

Commonest causes of valvular heart disease in general

Answer 22

Previous MI 
Rheumatic fever 
Infective endocarditis 
Congenital 
Age - deterioration and calcification

Question 23

Clinical signs of mitral stenosis

Answer 23

Malar flush
Early diastolic opening snap - diastolic rumble
Radiation to axilla

Question 24

Mitral regurgitation signs

Answer 24

Left parasternal heave
Displaced apex beat if volume overloaded
Pansystolic murmur

Question 25

What clinical signs to check for if suspicions of infective endocarditis

Answer 25

Dental hygiene Roth’s spots - eye Janeway lesions - painless on palm Osler’s nodes - painful in finger

Question 26

Common pathogens causing infective endocarditis

Answer 26

Strep viridans Staph aureus Staph epidermidis

Question 27

Investigations for murmurs

Answer 27

Bloods: FBC, U+E, lipids, glucose ECG: Left ventricular hypertrophy CXR - calcified AV Echo doppler - diagnostic

Question 28

Conservative mx for aortic stenosis

Answer 28

``` Medical: Optimise RFs: statins, anti-hypertensives, DM Monitor: regular follow up with echo Angina: β-B Heart failure: ACEi and diuretics Avoid nitrates ```

Question 29

Indications for valve replacement

Answer 29

Severe symptomatic AS Severe asymptomatic AS with ↓ EF (<50%) Severe AS undergoing coronary artery bypass graft or other valve operation

Question 30

Valve types

Answer 30

Mechanical valves: - last longer - need anticoagulation: young pts. ``` Bioprosthetic - don’t require anticoagulation but fail sooner (10-15yrs) ```

Question 31

Transcatheter Aortic Valve Implantation (TAVI)

Answer 31

Folded valve deployed in aortic root. ↑ perioperative stroke risk compared with replacement ↓ major bleeding

Question 32

Aortic regurgitation on CXR

Answer 32

Cardiomegaly Dilated ascending aorta Pulmonary oedema

Question 33

Signs of mitral stenosis

Answer 33

- ↑ left atrial pressure → loud S1 - Atrial hypertrophy → AF - pulmonary oedema and PHT → loud P2 - RVH → left parasternal heave - RHF → ↑JVP, oedema, ascites, Malar flush - Atrial dilation - Dysphagia, hoarse voice, dyspnoea