Murmurs/Valvular heart disease

Question 1

How can you amplify a MR murmur upon examination?

Answer 1

Ask patient to hold breath

Question 2

What does MR sound like?

Answer 2

high-pitched, “blowing” holosystolic murmur best heard at the apex. Can sound like ‘tss’

Question 3

What is the surface anatomy for aortic area when auscultating?

Answer 3

2nd intercostal space, right sternal boarder

Question 4

Surface anatomy for pulmonary area?

Answer 4

2nd intercostal space, left sternal boarder

Question 5

Surface anatomy for tricuspid area?

Answer 5

5th intercostal space, left sternal boarder

Question 6

Surface anatomy for mitral area?

Answer 6

5th intercostal space, midclavicular line

Question 7

Which manoeuvres can be done to amplify two murmurs?

Answer 7

MS- roll to left hand side

AR- sit up and lean forward, breathe out and hold

Question 8

Which acronym can be used to describe features of a murmur?

Answer 8

SCRIPT
Site- where is the murmur loudest?
Character- soft? blowing? crescendo? decrescendo?
Radiation- carotids? (AS), axilla? (MR)
Intensity- grade of murmur?
Pitch- high? low and grumbling? indicated velocity
Timing- systolic? diastolic?

Question 9

What is the process for grading murmurs?

Answer 9

Grade 1- difficult to hear
Grade 2- quiet
Grade 3- easy to hear
Grade 4- easy to hear with palpable thrill
Grade 5- hear with stethoscope barely touching chest
Grade 6- can hear murmur with stethoscope off the chest

Question 10

What are two causes of mitral stenosis?

Answer 10

rheumatic heart disease and infective endocarditis

Question 11

How to describe mitral stenosis murmur?

Answer 11

mid diastolic, low pitched, rumbling murmur. Loud S1

Question 12

Which sign of mitral stenosis can be seen in the face?

Answer 12

malar flush (back pressure of blood in pulmonary system, rise in CO2 and vasodilation)

Question 13

How can mitral regurgitation murmur be described?

Answer 13

pan-systolic murmur (heard throughout systolic period), high pitched whistling

Question 14

What are the causes of MR?

Answer 14

Idiopathic weakening with age, ischaemic heart disease, infective endocarditis, rheumatic heart disease, marfan’s syndrome

Question 15

How can aortic stenosis murmur be described?

Answer 15

ejection systolic murmur, high pitched, crescendo-decresceno

Question 16

Where can AS murmur radiate to?

Answer 16

carotid area

Question 17

What is the pulse pressure in AS?

Answer 17

narrow pulse pressure

Question 18

What are the causes of AS?

Answer 18

rheumatic heart disease and aging

Question 19

How can aortic regurgitation be described?

Answer 19

soft, early diastolic, very subtle murmur!!! Easily missed

Question 20

Which clinical sign is associated with aortic regurgitation?

Answer 20

collapsing pulse= corrigan’s pulse = rapidly appears and then disappears

Question 21

What is an austin flint murmur?

Answer 21

results from aortic regurgitation, heard at apex, early diastolic rumbling

Question 22

Causes of AR?

Answer 22

age related, marfan’s syndrome (connective tissue disorder, causes both aortic and mitral regurg)

Question 23

A patient is fluid overloaded. You auscultate heart valves and amazingly determine a mitral regurgitation murmur. You wonder whether to do an echo. How should you proceed?

Answer 23

Fluid overload can mimic MR, therefore do not echo until fluid overload has been resolved. Volume overload often occurs in response to mitral or aortic regurgitation, wherein a significant portion of blood ejected by the left ventricle in systole is not delivered to the systemic circulation, but instead is either returned to the left ventricle or delivered to the left atrium

Question 24

What are the surgical/radiological intervention for murmurs?

Answer 24

Prosthetic valve (shorter lifespan that metallic valves), metallic valves (lifelong anticoagulation with warfarin), and TAVI

Question 25

Which valve is TAVI only performed on?

Answer 25

aortic valve= transcatheter aortic valve implantation

Question 26

How to document heart sounds/murmurs?

Answer 26

HS I + II + murmur * AS- crescendo-decrescendo/ejection systolic MR- pansystolic

Question 27

How should your exam differ for thrills and heaves? Clue- hand

Answer 27

Thrills- use two fingers | Heave- use whole palm of hand

Question 28

How to distinguish between AS radiation and carotid bruit?

Answer 28

Bruit will only be heard in one carotid whereas AS will radiate to both

Question 29

What is the criteria score for infective endocarditis?

Answer 29

Duke's criteria

Question 30

List the triad of syx in AS

Answer 30

angina, dyspnoea, syncope

Question 31

Which type of heart failure arises in AS?

Answer 31

LVF

Question 32

Describe four symptoms of AS

Answer 32

angina, dyspnoea, syncope orthopnoea, frothy sputum arrhythmias

Question 33

List three clinical signs of AS

Answer 33

``` aortic thrill forceful apex beat Systolic ejection murmur narrow pulse pressure S4 ```

Question 34

List three differentials for AS

Answer 34

Coronary artery disease MR Aortic sclerosis

Question 35

What is the medical management for AS?

Answer 35

optimise risk factors- statins, antihypertensives, DM | treat associated disease- HF, angina

Question 36

What is the surgical management of AS?

Answer 36

Mechanical or prosthetic valve replacement

Question 37

What is a pro and con of mechanical heart valves?

Answer 37

Mechanical valves last longer but need | anticoagulation: young pts.

Question 38

Pro and con of prosthetic heart valves?

Answer 38

``` Bioprosthetic don’t require anticoagulation but fail sooner (10-15yrs) ```

Question 39

If heart valve replacement is contraindicated, what are the other options?

Answer 39

TAVI- transcatheter aortic valve implantation Balloon valvuloplasty

Question 40

List two causes of AR?

Answer 40

IE, rheumatic heart disease, Marfan's

Question 41

Describe three clinical signs of AR you would find on examination?

Answer 41

collapsing pulse Wide pulse pressure Displaced apex beat Ejection diastolic murmur

Question 42

What is corrigan's sign?

Answer 42

pulse that is bounding and forceful, rapidly increasing and subsequently collapsing- AR

Question 43

List two causes of mitral stenosis

Answer 43

Rheumatic fever Prosthetic valve Congenital

Question 44

List three clinical signs of mitral stenosis

Answer 44

malar flush Mid-diastolic murmur Raised JVP Left parasternal heave

Question 45

Why does malar flush arise in mitral stenosis?

Answer 45

CO2 retention, causing vasodilation of arterioles in cheeks

Question 46

Name one complication of MS

Answer 46

pulmonary HTN

Question 47

Three causes of MR?

Answer 47

``` rheumatic fever Marfan's/connective tissue disorder post-MI Calcification Mitral valve prolapse ```

Question 48

Two symptoms of all valvular abnormalities?

Answer 48

Dyspnoea, fatigue

Question 49

Three clinical signs of MR?

Answer 49

Displaced apex beat Pansystolic murmur AF Right ventricular heave

Question 50

Differential for MR?

Answer 50

AS, tricuspid regurg, ventricular septal defect

Question 51

Are semilunar valves more complicated than atrioventricular valves?

Answer 51

no they are much more simple, they are pressure controlled

Question 52

What are the components of the atrioventricular valves?

Answer 52

chordae tendinae and papillary muscles (and valve leaflets)

Question 53

What is the subvalvular apparatus and what is its function?

Answer 53

combination of chordae tendinae and papillary muscles. Prevents valve prolapse into the atria when they close

Question 54

What are symptoms of aortic stenosis?

Answer 54

shortness of breath, presyncope, syncope, chest pain, reduced exercise capacity

Question 55

What are the signs of aortic stenosis?

Answer 55

ejection systolic murmur, quiet second heart sound, narrowed pulse pressure, heaving apex beat (LVH), signs of heart failure

Question 56

De Mussett's (head nodding), Corrigan's carotid pulsation), and Quinke (nail bed pulsation), are signs of which disease?

Answer 56

Aortic regurg

Question 57

Name a structural valve disorder of the aortic valve

Answer 57

bicuspid aortic valve- valve is normally tri-leaflet but becomes bicuspid in appearance

Question 58

What are the standard assessments for valvular disease?

Answer 58

hx, examination, blood pressure, ECG, echo, CT, MRI