Murmurs Flashcards
Which murmurs are increased with inspiration
Right sided
Which murmurs are increased with expiration
Left sided
Systolic murmurs
Aortic stenosis
Mitral regurgitation
Tricuspid regurgitation
Diastolic murmurs
Aortic regurgitation
Mitral stenosis
Aortic stenosis on auscultation
Crescendo decrescendo systolic ejection murmur - exaggerated by sitting forward
Radiates to carotids
Soft S2 in very severe cases
Presentation of aortic stenosis
SAD:
Syncope
Angina
Dyspnoea
Dizziness Decreased pulse rate - slow rising pulse Aortic thrill Murmur Hypotension
Causes of aortic stenosis
Age related degeneration/ calcification
Congenital bicuspid valve - ejection click
Rheumatic fever - commiserate fusion
Consequences of aortic stenosis
- Increased end systolic volume causing LV hypertrophy causing LVHF
- microangiopathic haemolytic anaemia
- dizziness/LOC causing falls
Causes of aortic regurgitation
BEAR: Bicuspid aortic valve Endocarditis -Pupillary muscle or chordae tendinae degeneration Aortic root dilation Rheumatic fever
Other:
Marfans syndrome
Type A aortic dissection
Consequences of aortic regurgitation
Increased end systolic volume causing LV hypertrophy - LVHF
Increased systolic pressure and decreased end diastolic pressure - increased pulse pressure
Signs of aortic regurgitation
- 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
Causes of mitral regurgitation
Myxomatous degeneration Post MI pupillary muscle damage LVHF - left ventricular dilatation stretches valve Rheumatic heart failure Marfans
Mitral regurgitation murmur
Holosystolic or pansystolic
Loudest at apex
Radiates to axilla
Causes of mitral stenosis
Rheumatic fever - commisural fusion of leaflets
Consequences of mitral stenosis
Left atrium dilation - compresses oesophagus causing dysphagia AF - can cause thrombus formation Pulmonary oedema - dyspnoea Pulmonary hypertension RV hypertrophy - RVHF
Mitral stenosis murmur
Diastolic rumble
Ortner syndrome
Hoarseness of voice due to compression of recurrent laryngeal nerve and dysphagia
Causes of tricuspid regurgitation
Right ventricular dilatation due to RVHF
IVDU
Rheumatic fever
Infective endocarditis
Which organisms causing IE commonly affect the tricuspid valve?
Staph aureus
Pseudomonas
Candida
Relevant Investigations
Observations
Bloods - FBC, U+Es, LFTs, CRP - rheumatic fever
ECG
Echocardiogram
Management of aortic stenosis
- Minimise RF
- statins
- anti hypertensives
- diabetes control - Regular follow ups with echocardiogram
- If angina - beta blocker (avoid nitrates)
- If HF - furosemide and ACEi
- Surgery
Commonest causes of valvular heart disease in general
Previous MI Rheumatic fever Infective endocarditis Congenital Age - deterioration and calcification
Clinical signs of mitral stenosis
Malar flush
Early diastolic opening snap - diastolic rumble
Radiation to axilla
Mitral regurgitation signs
Left parasternal heave
Displaced apex beat if volume overloaded
Pansystolic murmur
What clinical signs to check for if suspicions of infective endocarditis
Dental hygiene
Roth’s spots - eye
Janeway lesions - painless on palm
Osler’s nodes - painful in finger
Common pathogens causing infective endocarditis
Strep viridans
Staph aureus
Staph epidermidis
Investigations for murmurs
Bloods: FBC, U+E, lipids, glucose
ECG: Left ventricular hypertrophy
CXR - calcified AV
Echo doppler - diagnostic
Conservative mx for aortic stenosis
Medical: Optimise RFs: statins, anti-hypertensives, DM Monitor: regular follow up with echo Angina: β-B Heart failure: ACEi and diuretics Avoid nitrates
Indications for valve replacement
Severe symptomatic AS
Severe asymptomatic AS with ↓ EF (<50%)
Severe AS undergoing coronary artery bypass graft or other valve operation
Valve types
Mechanical valves:
- last longer
- need anticoagulation: young pts.
Bioprosthetic - don’t require anticoagulation but fail sooner (10-15yrs)
Transcatheter Aortic Valve Implantation (TAVI)
Folded valve deployed in aortic root.
↑ perioperative stroke risk compared with replacement
↓ major bleeding
Aortic regurgitation on CXR
Cardiomegaly
Dilated ascending aorta
Pulmonary oedema
Signs of mitral stenosis
- ↑ 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
