Valvular Heart Disease + Murmurs Flashcards
What makes the S1 heart sound?
- closing of the atrioventricular valves
- at the start of systolic contraction of ventricles
What makes the S2 heart sound?
Closing of the semilunar valves
Once systolic contraction is complete
When is the S3 heart sound heard?
0.1s after S2 if present
When is the S4 heart sound heart?
What does it indicate?
Directly before S1
Stiff/hypertrophic ventricle > turbulent flow
(Hypertrophic cardiomyopathy)
Where is the best place to listen to the heart sounds?
Erb’s point
3rd ICS left sternal border
Where is Erb’s point?
3rd ICS left sternal border
What position can you put a patient in to listen to mitral stenosis clearer?
Turn the patient onto their left hand side
What position can you put the patient in to help you heard aortic regurgitation?
Sit up
Lean forward
Breathe out + hold
What features of a murmur do you need to assess?
SCRIPT
- Site
- Character
- Radiation
- Intensity
- Pitch - indicates velocity
- Timing - systolic or diastolic
What murmurs can radiate and where?
- aortic stenosis > carotids
- mitral regurgitation > axilla
How do you grade 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 with stethoscope off chest
What is atrial stenosis caused by?
- pts <65: bicuspid aortic valve
- pts >65: calcification
. - idiopathic age related calcification (most common)
- bicuspid aortic valve
- chronic kidney disease
- rheumatic heart disease
Describe an aortic stenosis murmur
- ejection-systolic high pitched murmur
- crescendo-decrescendo character
- radiates to the carotids
- louder on expiration
Signs of aortic stenosis
- chest pain
- dyspnoea
- exertional syncope
- ejection systolic high pitched murmur
- crescendo-decrescendo
- radiates to carotids
.
severe: - thrill on palpation
- slow rising pulse
- narrow pulse pressure
Three classical symptoms of aortic stenosis
Angina
Heart failure
Syncope
What can aortic stenosis cause?
- microangiopathic haemolytic anaemia
- LV hypertrophy
- left sided heart failure > angina + syncope
Indications for surgery in an aortic stenosis patient
- symptoms caused by AS (regardless of severity)
- asymptomatic severe AS with LVSD
- asymptomatic severe AS with abnormal exercise test
- asymptomatic severe AS at time of other cardiac surgery
Management options of aortic stenosis
- surgical aortic valve replacement in younger low risk
- transcatheter AVR if high operative risk
- balloon valvuloplasty in children with no calcifications
What causes aortic regurgitation?
- idiopathic age related weakness
- bicuspid aortic valve
- connective tissue disorders e.g. Marfan’s syndrome, Ehlers-Danilo’s syndrome
- spondyloarthropathies
- rheumatic disease
- infective endocarditis
Describe an aortic regurgitation murmur
- early diastolic soft murmur
- can cause an Austin-Flint murmur - heart attack apex as diastolic rumbling due to blood regurgitating + causing mitral valve to vibrate
- may be better heard if you ask patient to sit up, lean forwards, breathe in + hold
What are the signs of aortic regurgitation?
- early diastolic soft murmur
- rumbling murmur in apex
- thrill on palpation
- collapsing pulse
- wide pulse pressure
- heart failure + pulmonary oedema
- De Musset’s sign (head bobbing)
- Quincke’s sign (nailbed pulsation)
What are the indications for surgery in aortic regurgitation patients?
- symptomatic severe AR
- asymptomatic severe AR with early LVSD
- asymptomatic AR of any severity with aortic root dilation
What position can you put the patient in to heard aortic regurgitation better?
Sit up
Lean forward
Breathe in + hold
What causes mitral stenosis?
- rheumatic heart disease
- infective endocarditis
Describe the murmur in mitral stenosis
- mid-late diastolic low pitched rumbling
- snap as valve opens followed by diastolic rumble
- better heard if you turn patient to their left side
How can you position the patient to better heard mitral stenosis
Turn them to their left side
Signs of mitral stenosis
- mid diastolic low pitched rumbling + opening snap
- tapping apex beat
- malar flush
- AF
- haemopytsis
what can mitral stenosis cause?
- increased LA pressure > LA dilation:
- AF > thrombus fomration
- oesophagus compression > dysphagia
- increased LA pressure > pulmonary oedema + hypertension > RV hypertrophy
Management of mitral stenosis
- monitor asymptomatic pts with echo
- if pt has AF, anticoagulation - warfarin
- symptomatic pts: mitral balloon valvotomy or mitral valve replacement
What causes mitral regurgitation?
- idiopathic weakening of the valves with age
- ischaemic heart disease - post MI
- infective endocarditis
- rheumatic heart disease
- connective tissue disorders e.g. Ehlers-Danlos syndrome, Marfan syndrome
risk factors of mitral reguritations
- female
- low BMI
- age
- prior MI or mitral stenosis
- collagen disorders e.g. Marfan’s + Ehlers-Danlos syndrome
Describe the murmur is mitral regurgitation
- pansystolic, high pitched whistling
- radiates to left axilla
Signs of mitral regurgitation
- pansystolic high pitched whistling murmur
- Thrill in mitral area on palpation
- heart failure signs + pulmonary oedema
- AF
Indications for surgery in mitral regurgitation patients
- symptomatic MR
- asymptomatic MR with mild-moderate LV dysfunction
Pharmacological therapy of mitral regurgitation
- diuretics
- if LVSD is present, treatment with ACEi + B blockers + CRT have reduced severity of MR
What does mitral regurgitation cause?
- LV hypertrophy
- reduced EF > congestive heart failure
What is used in assessment + investigations of valvular disease?
Echocardiogram
Can assess severity + impact on rest of the heart e.g. LV function
What does a collapsing pulse indicate?
Aortic regurgitation
Blood flows back into heart as you lift arm up
What does a pansystolic murmur indicate?
Mitral regurgitation
What does an ejection systolic high pitched murmur indicate?
Aortic stenosis
What does an early diastolic soft murmur indicate?
Aortic regurgitation
What does a snap followed by a mid diastolic low pitched rumbling murmur indicate?
Mitral stenosis
What is Rheumatic Heart disease?
A condition where the heart valves have been permanently damaged by repeated episodes of rheumatic fever
Link between a sore throat and rheumatic heart disease
- starts as a sore throat (strep pyogenes)
- causes an autoimmune reaction (rheumatic fever)
- repeated episodes of RF cause chronic inflammation + scarring of heart valves
- causing rheumatic heart disease`
What murmurs are seen in Marfan’s + Ehlers Danlos sydnrome
aortic reguritation
mitral reguritation
Describe the murmurs heard in:
- aortic stenosis
- aortic regurgitation
- mitral stenosis
- mitral reguritation
- tricuspid regurgitation
- patent ductus arteriosus
- aortic stenosis: ejection systolic - crescendo-decrescendo
- aortic regurgitation: early diastolic blowing
- mitral stenosis: mid-late diastolic rumbling
- mitral/tricuspid regurgitation: holosystolic/pansystolic
- patent ductus arteriosus: continuous machine like murmur
What are the systolic murmurs
aortic stenosis
mitral reguritation
what are the diastolic murmurs
aortic regurgitation
mitral stenosis
