Murmurs/Valvular heart disease Flashcards
How can you amplify a MR murmur upon examination?
Ask patient to hold breath
What does MR sound like?
high-pitched, “blowing” holosystolic murmur best heard at the apex. Can sound like ‘tss’
What is the surface anatomy for aortic area when auscultating?
2nd intercostal space, right sternal boarder
Surface anatomy for pulmonary area?
2nd intercostal space, left sternal boarder
Surface anatomy for tricuspid area?
5th intercostal space, left sternal boarder
Surface anatomy for mitral area?
5th intercostal space, midclavicular line
Which manoeuvres can be done to amplify two murmurs?
MS- roll to left hand side
AR- sit up and lean forward, breathe out and hold
Which acronym can be used to describe features of a murmur?
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?
What is the process for grading murmurs?
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
What are two causes of mitral stenosis?
rheumatic heart disease and infective endocarditis
How to describe mitral stenosis murmur?
mid diastolic, low pitched, rumbling murmur. Loud S1
Which sign of mitral stenosis can be seen in the face?
malar flush (back pressure of blood in pulmonary system, rise in CO2 and vasodilation)
How can mitral regurgitation murmur be described?
pan-systolic murmur (heard throughout systolic period), high pitched whistling
What are the causes of MR?
Idiopathic weakening with age, ischaemic heart disease, infective endocarditis, rheumatic heart disease, marfan’s syndrome
How can aortic stenosis murmur be described?
ejection systolic murmur, high pitched, crescendo-decresceno
Where can AS murmur radiate to?
carotid area
What is the pulse pressure in AS?
narrow pulse pressure
What are the causes of AS?
rheumatic heart disease and aging
How can aortic regurgitation be described?
soft, early diastolic, very subtle murmur!!! Easily missed
Which clinical sign is associated with aortic regurgitation?
collapsing pulse= corrigan’s pulse = rapidly appears and then disappears
What is an austin flint murmur?
results from aortic regurgitation, heard at apex, early diastolic rumbling
Causes of AR?
age related, marfan’s syndrome (connective tissue disorder, causes both aortic and mitral regurg)
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?
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
What are the surgical/radiological intervention for murmurs?
Prosthetic valve (shorter lifespan that metallic valves), metallic valves (lifelong anticoagulation with warfarin), and TAVI
Which valve is TAVI only performed on?
aortic valve= transcatheter aortic valve implantation
How to document heart sounds/murmurs?
HS I + II + murmur *
AS- crescendo-decrescendo/ejection systolic
MR- pansystolic
How should your exam differ for thrills and heaves? Clue- hand
Thrills- use two fingers
Heave- use whole palm of hand
How to distinguish between AS radiation and carotid bruit?
Bruit will only be heard in one carotid whereas AS will radiate to both
What is the criteria score for infective endocarditis?
Duke’s criteria
List the triad of syx in AS
angina, dyspnoea, syncope
Which type of heart failure arises in AS?
LVF
Describe four symptoms of AS
angina, dyspnoea, syncope
orthopnoea, frothy sputum
arrhythmias
List three clinical signs of AS
aortic thrill forceful apex beat Systolic ejection murmur narrow pulse pressure S4
List three differentials for AS
Coronary artery disease
MR
Aortic sclerosis
What is the medical management for AS?
optimise risk factors- statins, antihypertensives, DM
treat associated disease- HF, angina
What is the surgical management of AS?
Mechanical or prosthetic valve replacement
What is a pro and con of mechanical heart valves?
Mechanical valves last longer but need
anticoagulation: young pts.
Pro and con of prosthetic heart valves?
Bioprosthetic don’t require anticoagulation but fail sooner (10-15yrs)
If heart valve replacement is contraindicated, what are the other options?
TAVI- transcatheter aortic valve implantation
Balloon valvuloplasty
List two causes of AR?
IE, rheumatic heart disease, Marfan’s
Describe three clinical signs of AR you would find on examination?
collapsing pulse
Wide pulse pressure
Displaced apex beat
Ejection diastolic murmur
What is corrigan’s sign?
pulse that is bounding and forceful, rapidly increasing and subsequently collapsing- AR
List two causes of mitral stenosis
Rheumatic fever
Prosthetic valve
Congenital
List three clinical signs of mitral stenosis
malar flush
Mid-diastolic murmur
Raised JVP
Left parasternal heave
Why does malar flush arise in mitral stenosis?
CO2 retention, causing vasodilation of arterioles in cheeks
Name one complication of MS
pulmonary HTN
Three causes of MR?
rheumatic fever Marfan's/connective tissue disorder post-MI Calcification Mitral valve prolapse
Two symptoms of all valvular abnormalities?
Dyspnoea, fatigue
Three clinical signs of MR?
Displaced apex beat
Pansystolic murmur
AF
Right ventricular heave
Differential for MR?
AS, tricuspid regurg, ventricular septal defect
Are semilunar valves more complicated than atrioventricular valves?
no they are much more simple, they are pressure controlled
What are the components of the atrioventricular valves?
chordae tendinae and papillary muscles (and valve leaflets)
What is the subvalvular apparatus and what is its function?
combination of chordae tendinae and papillary muscles. Prevents valve prolapse into the atria when they close
What are symptoms of aortic stenosis?
shortness of breath, presyncope, syncope, chest pain, reduced exercise capacity
What are the signs of aortic stenosis?
ejection systolic murmur, quiet second heart sound, narrowed pulse pressure, heaving apex beat (LVH), signs of heart failure
De Mussett’s (head nodding), Corrigan’s carotid pulsation), and Quinke (nail bed pulsation), are signs of which disease?
Aortic regurg
Name a structural valve disorder of the aortic valve
bicuspid aortic valve- valve is normally tri-leaflet but becomes bicuspid in appearance
What are the standard assessments for valvular disease?
hx, examination, blood pressure, ECG, echo, CT, MRI
