Murmurs/valvular disease Flashcards
Valvular heart disease
What are your systolic murmurs?
Aortic stenosis
Mitral regurgitation
Tricuspid regurgitation
What are your diastolic murmurs?
Aortic regurgitation
Mitral stenosis
ARMS- 2 of them aka di-astolic [di=2]
What is the epidemiology of systolic murmurs?
3% of 75 yr olds
M>F
What are the general symptoms of systolic murmurs?
Exertional dyspnoea
Heart failure signs
Patients may be ASx
What are the signs of aortic stenosis?
Narrow pulse pressure
Slow rising pulse
Heaves and thrills
Reduced/absent S2 (indicates severity)
What are the signs of mitral regurgitation?
Normal/irregularly irregular pulse
Laterally displaced apex beat
What are the signs of tricuspid regurgitation?
Raised JVP Parasternal heave Pulsatile hepatomegaly (RHF) Signs of RHF (pleural effusion, hepatomegaly, ascites, pitting oedema)
Where does an aortic stenosis murmur radiate to?
The right carotid artery
Where does a mitral murmur radiate to?
The left axilla
What murmur is accentuated upon expiration and leaning forwards?
Aortic regurgitation
What murmur is accentuated upon expiration and leaning to the left?
Mitral stenosis and regurgitation
What murmurs are accentuated upon inspiration?
Tricuspid and pulmonary murmurs
Which murmur would be present if a CXR showed aortic valve calcification?
Aortic stenosis
Which murmur would be present if a CXR showed right sided enlargement?
Tricuspid regurgitation
Which murmur would be present if a CXR showed cardiomegaly calcification?
Mitral regurgitation
Rheumatic heart disease characteristically causes which valvular defect?
Mitral stenosis
What are the symptoms of diastolic murmurs (AR/MS)?
Dyspnoea Syncope on exertion Angina HF signs Palpitations Orthopnoea Weakness (particularly AR)
Patients may be ASx
What would you palpate on examination of a Pt with AR?
Wide pulse pressure
Water hammer pulse
Displaced apex beat
What would you see/palpate on examination of a Pt with MS?
Malar flush
Thready/irregularly irregular pulse
Tapping apex, parasternal heave
Which is the early diastolic and which is the mid diastolic murmur?
Early diastolic- aortic regurgitation
Mid diastolic- mitral stenosis
A 49-year-old woman presents with increasing shortness of breath on exertion developing over the past three months. She has no chest pain or cough, and has noticed no ankle swelling. On examination, blood pressure is 158/61mmHg, pulse is regular at 88 beats per minute and there are crackles at both lung bases. There is a decrescendo diastolic murmur at the left sternal edge. What is the most likely diagnosis?
A. Aortic regurgitation B. Aortic stenosis C. Mitral regurgitation D. Mitral stenosis E. Tricuspid regurgitation
A. Aortic regurgitation
Note the wide pulse pressure, the lung base crackles, and the decrescendo diastolic murmur on the LEFT sternal edge (AS is heard at the right sternal edge)
You see a 57-year-old woman who presents with worsening shortness of breath coupled with decreased exercise tolerance. She had rheumatic fever in her adolescence and suffers from essential hypertension. On examination, she has a mid-diastolic murmur heard loudest over the mitral area. Which of the following is not a clinical sign associated with this particular diagnosis?
A. Malar flush B. Atrial fibrillation C. Pan-systolic murmur which radiates to axilla D. Tapping, un-displaced apex beat E. Right ventricular heave
C. Pan-systolic murmur which radiates to axilla
Note the Rheumatic heart disease, and murmur loud at the mitral area indicates mitral stenosis, which is a mid-diastolic murmur.
An 8 year old boy comes to the GP with his mother for a check-up. You find the child to be extremely sociable and friendly, with some mild learning difficulties. You also note distinct facial features including broad forehead, short nose and full cheeks. On auscultation of his chest, you detect a murmur in the right 2nd intercostal space, loudest on expiration. What is the most likely diagnosis?
A. Hypertrophic obstructive cardiomyopathy B. Infective endocarditis C. Aortic stenosis D. Aortic regurgitation E. Mitral stenosis
C. Aortic stenosis
There were no indications of infx, or HOCM. Mitral stenosis tends to develop with Rheumatic heart disease, which the child did not have. Aortic regurgitation is heard louder on the left sternal border.
Which murmurs are louder on expiration?
LEFT (mitral/aortic)
↑intrathoracic pressure –> forces pulmonary vessels to constrict –> blood is forced from pulmonary veins –> LHS
Which murmurs are louder on inspiration?
RIGHT (pulmonary/tricuspid
↓ intrathoracic pressure –> more blood flows into RHS
Symptoms of AS
Exertional chest pain/angina
SYNCOPE in 40% – due to arrhythmia or postural hypotension
(In addition to systolic murmur signs- exertional dyspnoea + HF signs)
Symptoms of MR
Decreased exercise tolerance
Peripheral oedema
(In addition to systolic murmur signs- exertional dyspnoea + HF signs)
Symptoms of TR
Palpitations, arrhythmia
In addition to systolic murmur signs- exertional dyspnoea + HF signs
Causes of AS?
Degenerative age-related calcification (commonest)
Bicuspid aortic valve (important in a young person)
Congenital: William’s syndrome
Describe the classic AS murmur
EJECTION SYSTOLIC MURMUR
Loudest over aortic area
Radiates to carotids and apex
Loudest on expiration and leaning forwards
Causes of mitral regurgitation
Degenerative age-related calcification
LV dilatation
Rupture of chordae tendinae
Papillary muscle rupture
Describe the classic MR murmur
PAN SYSTOLIC MURMUR
Loudest over mitral area
Radiates to axilla
Loudest in left lateral position with bell of stethoscope
What would you find on palpation in MR?
Pulse – normal/irregularly irregular
Laterally displaced apex beat
Causes of TR
RV dilatation Rheumatic fever INFECTIVE ENDOCARDITIS (IVDU) Carcinoid syndrome Congenital – Ebstein anomaly
Describe the classic TR murmur
PAN SYSTOLIC MURMUR
Loudest over tricuspid region
Loudest on inspiration
Causes of aortic regurgitation
Ascending aortic arch dissection
Connective tissue disease (e.g. Marfan syndrome, Ehlers-Danlos syndrome)
Infective endocarditis
Rheumatological disorders
Many causes, these are key ones
What are the signs of AR?
Corrigan’s sign- distended neck veins
Quincke’s sign (pulsating nail bed capillaries)
Wide pulse pressure
Collapsing/’water hammer’/Corrigan’s pulse
Displaced apex beat
Describe the classic AR murmur
EARLY DIASTOLIC MURMUR
Heard loudest over LSE and aortic area
If severe- radiates to apex
Loudest on leaning forward and on expiration
What is a sign of severe AS?
Austin Flint murmur
Blood regurgitates through the aortic valve mixing with blood from the left atrium, during atrial contraction
Describe austin flint murmur
Low pitched rumbling
Mid-diastolic murmur
Best heard at the apex
Causes of MS
RHEUMATIC HEART DISEASE (commonest) Congenital Left atrial myxoma Connective tissue disorders Mucopolysaccharidosis
Describe the classic MS murmur
MID DIASTOLIC MURMUR
Loud S1 with opening snap:
- snap as the mitral valve opens
- mitral valve closes against high left atrial pressure, causing a loud S1
Loudest in apex + left lateral position with bell of stethoscope
Low rumbling murmur
Signs of MS on inspection/palpation
malar flush
Pulse – ‘thready’, low volume or AF
Palpation – TAPPING APEX, parasternal heave
Slow rising pulse - Ax
AS
Heaving apex beat - Ax
AS
Parasternal heave - Ax
MS
