Murmurs - Johns Flashcards
What is the grade of most murmurs?
III
When does diastole occur?
After S2
Describe an aortic stenosis murmur:
- Early to mid-systolic
- Heard best over base and tends to radiate to carotids
- Crescendo-decresendo
- Late stages may have decreased systolic pressure and slow carotid upstroke (rather than a tapping pulsation)
What is the etiology of Aortic Stenosis?
Degenerative calcific, rheumatic, bicuspid
What is the pathophysiology of aortic stenosis?
Pressure gradient over 50 mm or valve area represents critical obstruction (1/3 of normal valve area)
What are the symptoms of Aortic Stenosis?
Angina, syncope, dyspnea on exertion
What is the treatment for Aortic Stenosis?
- Valve replacement
- Balloon valvuloplasty in children and young adults
Describe a mitral insufficiency (regurgitation):
- Even, blowing murmur
- Holosystolic murmur
- Heard best at apex, tends to radiate to the axilla (putting stethoscope on axilla to hear it)
What is the etiology for Mitral Insufficiency?
RHD, congenital, acute MI with papillary muscle dysfunction, endocarditis, calcification with age
What is the pathophysiology of Mitral Insufficiency?
Decreased forward flow
Acute - little enlargement of left atrium, pulmonary edema
Chronic - large left atrium
What are the symptoms of Mitral Insufficiency?
Acute - pulmonary edema
Chronic - Severe fatigue, atrial fibrillation
What are the treatments of Mitral Insufficiency?
- Medical treatment for CHF, atrial fibrillation
- Surgery: patients with severe MR with limitations of work or routine household tasks
Describe Mitral Stenosis:
- Diastolic murmur best heard at apex with patient in left lateral recumbent position
- Low pitched (rumble)
- Opening snap precedes murmur
What is a typical mitral stenosis case?
Women from Nigeria, pregnant in 2nd trimester with pulmonary edema - has mitral stenosis
What is the etiology of mitral stenosis?
Most are rheumatic, rarely congenital
-Decreased incidence since strep treatment
What is the pathophysiology of mitral stenosis?
- Normal valve orifice is 4-5 cm2, left atrial pressure rises with 2 cm2
- Pulmonary hypertension
- Resultant right ventricular failure
What symptoms are associated with mitral stenosis?
- Dyspnea with exertion and cough
- Hemoptysis
- Arterial embolism
What is the treatment for mitral stenosis?
- Antibiotic prophylaxis
- CHF, Atrial fibrillation - Valve replacement if valve area less than 1.0 cm2
Describe Aortic Insufficiency (regurgitation):
-High pitched diastolic murmur heard best at base of heart
When is aortic insufficiency best heard?
With patient sitting
- Louder with inc. severity
- “water-hammer” pulse, increased pulse pressure
What is the etiology of aortic insufficiency?
2/3 are rheumatic - Endocarditis, trauma (car accidents), congenital
What is the pathophysiology of aortic insufficiency?
Increased SV
-Deterioration of left ventricular function precedes symptoms
What are the symptoms of aortic insufficiency?
- May be asymptomatic for years
- Uncomfortable awareness of heartbeat when lying down, exertion dyspnea first symptom followed by orthropnea and PND - Angina, CHF
How do you treat aortic insufficiency?
Difficult to time: Patients asymptomatic until myocardial dysfunction develops
-Myocardial dysfunction does not return after surgery
Describe Mitral Valve Prolapse:
- Click-murmur syndrome
- Mid or late systolic click
- May be followed by a high pitched late systolic murmur
- Heard best at the apex
What is the etiology of mitral valve prolapse?
Congenital or genetic, very common, females between 14-30
What is the pathophysiology of mitral valve prolapse?
Myxomatous degeneration of posterior leaflet
-Usually benign but may trigger arrhythmias
How do you treat mitral valve prolapse?
Reassure
What are innocent murmurs?
- Always systolic ejection in nature
- Occur without evidence of physiologic abnormalities
- Grade I or II intensity
- No thrills or radiation
- End well before S2
- Found in 30-50% of children
What are three right sided murmurs?
- Tricuspid stenosis
- Tricuspid regurgitation
- Pulmonic stenosis
What is Tricuspid stenosis?
Rare in developed countries, rheumatic, associated with mitral stenosis, giant A wave in neck, diastolic murmur best heard along lower left sternal border and xiphoid (right ventricular failure –> most often caused by left sided failure)
What is tricuspid regurgitation?
Functional from right ventricular dilation, signs of right sided heart failure, holosystolic murmur at LLSB, prominent v waves in neck
What is pulmonic stenosis?
-Usually preceded by ejection click, mid systolic murmur like this is probably benign.
