Murmurs (CM) Flashcards
Causes of aortic stenosis
Degenerative Bicuspid valve in the young Rheumatic (often with mitral disease) Atherosclerosis Rare (irradiation, collagen disease)
Most common cause of valvular disease
Aortic stenosis
Symptoms of aortic stenosis
“Congestive failure” bc L ventricular obstruction; dyspnea 50%
Angina 30%
Syncope with exercise intolerance
Death rarely presenting symptom except in kids
Most people are asymptomatic, but once they develop, half die in 2-5yrs
Physical exam findings of aortic stenosis
Palpable S4 with heave
Thrill over aortic region
Midsystolic ejection murmur that radiates up neck and along L sternal border
MURMUR GETS QUIETER WITH DISEASE PROGRESSION.
Management of asymptomatic aortic stenosis
Get baseline echo
No competitive athletics
Avoid vasodilators (decrease after load and CO)
F/u with echo every 2 or 5 years depending on severity
Management of symptomatic aortic stenosis
Once symptoms arise, it is lethal so if they are good surgical risk, valve replacement
Substantial hemodynamic and clinical improvement after procedure
Second most common valvular disease
Mitral stenosis
Causes of mitral stenosis
Rheumatic fever–almost all mitral stenosis is a complication after. Usually seen in pts 40-50 y.o.
Rare–congenital or non bacterial thrombotic endocarditis
Symptoms of mitral stenosis
Symptoms tend to be subtle and slow: Exercise intolerance Congestive failure-edema, orthopnea, DOE, PND Hoarseness-recurrent laryngeal nerve A fib in elderly Palpitations as progresses
Physical exam findings of mitral stenosis (moderately severe disease)
Sinus rhythm.
Low frequency, mid diastolic rumble heard best at the apex in the L lateral decubitus position
Opening snap after P2
S1 increased and palpable at LSB
Physical exam findings of severe mitral stenosis
A fib
Same murmur, no opening snap
R ventricular heave over apex bc fluid backed up in L atria
Maller flush
Complications of mitral stenosis
Early stage murmurs are often missed, if suspicious have patient do sit up or valsalva maneuver
As progresses, have L atrial enlargement which can lead to thrombi, especially with a fib
HR is critical to evaluating. As HR increases, there is less time for diastolic filling leading to pulmonary HTN
Management of mitral stenosis
Yearly echo
Negative chronotrophs (BB or CCB)
Tx a fib as needed
Low level aerobics to maintain cardio health
Surgical: balloon valvulopasty (early) or replacement (severe)
Timing of intervention of pts with mitral stenosis
Definite: clear sxs of heart failure not related to a fib or severe exercise intolerance
Possibly: moderate-severe pulmonary HTN
Non indicated: no symptoms
Causes of mitral prolapse
Congenital, autosomal dominant inheritance, connective tissue disorders (Marfans, Duchenne MD, Graves)
Symptoms of mitral valve prolapse
Most of the time none
Palpitations most common Chest pains Arrhythmia exercise intolerance Cerebral emboli and sudden death very rare
Physical exam findings of mitral valve prolapse
Murmur: usually late systolic, preceded by click, heard best at apex and LLSB
Opening sound of prolapsed valve returning to position during early diastole
Click and murmur highly variable May need to accentuate with squatting or valsalva
Systolic whoop or honk=Pathognomonic
Management of mitral valve prolapse
BB if have sxs consistent with increased sympathetic tone (palpitations), also increases a fib threshold
Exclude any connective tissue disorder
Reassure most are benign
Middle aged males most likely to have mechanical complications
Causes of severe chronic aortic regurgitation
degeneration bicuspid valve Rheumatic Heart Disease (with mitral diseae) trauma infectious endocarditis
Causes of mild aortic regurgitation
bicuspid valve with severe HTN
Causes of acute aortic regurgitation
Chest trauma
Endocarditis
Rare causes of aortic regurgitation
Connective tissue disorder
Collagen vascular disorder
Symptoms of aortic regurgitation
Acute: dyspnea, orthopnea Chronic: worsening exercise intolerance "Congestive failure" Angina in only about 5% of patients--worse at night because HR slows Bounding peripheral pulses
Physical Exam findings of aortic regurgitation
Pandiastolic murmur that is blowing, high pitch, heard best of LLSB
With severe disease the PMI can be displaced laterally and to the left
Management of aortic regurgitation
Asymptomatic with nl LV systolic function
Need echo a 1-2 years
Vasodilator to maintain EF
High survival rate
If progressive LV dilation or decrease EF, >25% will progress. Sxs with decreased EF and poor functionally capacity–>Need surgery!
Causes of mitral regurgitation
Primary: leaflet, annular, or chordae/papillary muscle abnormalities; or mitral valve prolapse
Secondary: LV dilation or endocardial cushion defect from IHD
Symptoms of mitral regurgitation
Frequently no symptoms
Ischemic heart symptoms
Exercise intolerance
Palpitations long before congestive failure begins
In severe mitral regurgitation, high atrial pressure causes dyspnea.
May lead to atrial hypertrophy and a fib
Physical exam findings in mitral regurgitation
Murmur: systolic, harhs and blowing, high pitched, heard best over apex, and may radiate to left axilla Thrill may be palpable at the apex Large and prominent PMI Brisk pulse LSB heave due to enlarged L atrium
Signs of severe mitral regurgitation
Intensity of murmur does not correlate to severity
Evidence of pulmonary HTN and volume overload
EKG: LV hypertrophy, a.fib or BBB
Murmur findings that differentiate causes of mitral regurgitation
papillary muscle dysfunction–>crescendo to S2
Mitral valve prolapse–>delayed, preceded by click
posterior ruptured chordae–>mimic aortic stenosis and radiate to 2nd R interspace
anterior ruptured chordae–> radiate to spine and top of head
Management of mitral regurgitation
SURGERY is the tx for ANY LV dysfunction
Regurgitant lesions can cause L ventricular damage before sxs occur
Once EF fall below 60% prognosis worsens
Can use ACEI to decrease afterload
Evaluate yearly with color doppler to quantify severity
CXR of moderate to severe show enlarged L atrium and ventricle, and pulmonary congestion
Prognosis for surgery is poor for pts with IHD
Cardiac conditions that require prophylactic antibiotics
Hx of endocarditis
Congenital defects
Prosthetic valves
Cardiac transplant recipients with cardiac valvular disease
