533 > Week 6 Heart Murmurs > Flashcards

Week 6 Heart Murmurs Flashcards

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1
Q

infectious endocarditis

A
  • microbial infection w/in endothelium of heart veg
  • vegetation forms on endothelial structures
  • 50% are > 50 yrs old (2men:1women)
  • acute: death days-6wks: staph aureus
  • subacute: death 6 wks-3 months: & chronic: death > 3 months
    • viridan’s streptococci
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2
Q

Native valve endocarditis

A
  • most common type of IE
  • affects mitral, aortic or BOTH
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3
Q

*risk factors of infectious endocarditis

A
  • IV drug use
  • structural cardiac abnormalities
  • implantable devices
  • cardiac/vascular prostheses
  • immunosuppression
  • IE hx
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4
Q

IE clinical presentation

A
  • fever
    • (absent in elderly, immune comp, CHF, renal failure, tx’ed with previous antibiotics)
  • chills, weight loss
  • conduction disturbances, heart block, pericarditis, fistulas, fibrosis leaflets
  • murmurs
  • CHF (poor prognosis)
  • emboli
    • neurologic or opthalmologic → Roth spots
    • PE - IVDU or indwelling central line
    • splenic septic emboli
  • petechiae
    • janeway lesions - macules palms, soles from septic embolization
    • osler nodes - painful nodules finger, toe pads
  • renal failure
  • arthralgias/myalgias
    • proximal joints/lower extremities, monocular unilateral
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5
Q

infectious endocarditis diagnostics

A
  • gold standard to dx: THREE sets of blood cultures (from 3 diff sites before antib started)
    • 2nd set 1 hr after 1st
  • CBC
  • CRP/ESR
  • EKG
    • continuous monitoring for perivalvular abscess
  • TransthoracicEcho (TTE)
  • TransesophagealEcho (TEE)
  • cardiac CT if echo not clear
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6
Q

Infectious endocarditis management/treatment

A
  • transfer to ED if have fever and sus IE! consult specialist
  • infectious dz consult: IV antibiotics (IV!! only)
    • improve in 1 week - recheck cx’s (should be - )
  • if fungal org → antifungals + valve replacement surgery
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7
Q

**infectious endocarditis prophylaxis for dental, oral, respiratory procedures and WHAT ANTIB?

A
  • antibiotics prior to procedure (dental or other surgical procedures)
  • cardiac transplant and valvulopathy
  • Prosthetic valve
  • prosthetic material in valve repair w/in first 6 months of surgery
  • hx of infectious endocarditis
  • amoxicillin oral 2g once 30-60 mins before procedure
    • or clindamycin oral 600 mg if PCN allergy
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8
Q

if suspect IE…

A

refer to ED!!! ideally with cardiac surgery availability

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9
Q

where is aortic area?

A

Right upper sternal border or 2nd ICS

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10
Q

**where is pulmonic area?

A

Left upper sternal border or 2nd intercostal space

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11
Q

where is the tricuspid area?

A

left lower sternal border

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12
Q

where is the mitral area?

A

apex

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13
Q

Grade III murmur

A

moderately loud

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14
Q

Grade IV murmur

A

loud, palpable thrill

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15
Q

grade V murmur

A

very loud with thrill, heard when stethoscope partly off chest

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16
Q

early systolic murmur

A
  • least common
  • high pitched, sharp
  • pathologic
  • mitral or tricuspid regurgitation
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17
Q

*midsystolic murmur

A
  • most common
  • crescendo-decrescendo that build in intensity as velocity increases then decreases well before S2
  • heard in aortic or PS
  • valsalva maneuver increases murmur in hypertrophic cardiomyopathy
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18
Q

late systolic murmur

A
  • start mid or late systole
  • continue to s2 in crescendo pattern
  • in MVP or tricuspid valve prolapse
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19
Q

pansystolic

A
  • result from blood flow transferring from high pressure chamber to low pressure
  • mitral regurgitation or tricuspid valve or VSD
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20
Q

what does diastolic murmurs indicate

A

pathologic and heart disease bc of regurgitation or stenosis

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21
Q

*Stills murmur

A
  • benign innocent murmur
  • classic vibratory/musical parasternal precordial murmur
  • mid systolic
  • mid left sternal border and apex
  • common in healthy infants, children 3-6 yrs or 8-12 yrs
  • asymptomatic, no abnormal findings
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22
Q

****when to refer with murmurs?

A

pathologic murmurs:

  • diastolic, holosystolic murmur
  • grade 3 and up systolic murmurs
  • murmur with extra heart sounds (S3, S4, or click)
  • murmur that increases in intensity when pt stands
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23
Q

murmur diagnostics

A
  • EKG
  • chest xray
  • ECHO
  • stress test if asx severe VHD
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24
Q

Stages of valvular heart disease

A
  • Stage A: has risk factors
  • Stage B: with progressive VHD (mild-mod, asx)
  • Stage C: Asx with severe VHD
    • C1 - asx w/ severe VHD with L or R ventricle compensating
    • C2 - asx w/ severe VHD with decompensation of L or R ventricle
  • Stage D: have sx’s
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25
\*valvular heart disease complications
* heart failure * volume overload → leads to changes in heart muscle wall * reduced functional status * L ventricular pump failure * Death - from dysrhythmias
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NP role in VHD
* history - know risk factors in PMH * PE - recognize early heart sound changes * aus / inspect chest wall, palp pulse, PMI * diagnosis - if SOB, fatigue, edema, new murmur * get diagnostics and refer * refer to Level 2 primary valve center - surgery (w/w/o CABG) or Level 1 for transcatheter valve replacement
27
Systolic murmurs
MR. Peyton Manning AS MVP * Mitral regurgitation * physiological murmur * aortic stenosis * mitral valve prolapse
28
diastolic murmurs
ARMS * aortic regurgitation * Mitral Stenosis
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steps to find a murmur
1. systolic or diastolic? if carotid pulsing same time as chest = systolic murmur 2. MR PEYTON MANNING AS MVP or ARMS 3. Location: All Pt's E. Take Meds
30
aortic stenosis etiologies
* Ages 15-65 * usually congenital, rheumatic fever is 2nd most common cause, calcified * If rheumatic fever is the cause than usually the mitral valve is involved too * asx til 5-6th decade then rapid deterioration at onset of sx
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*aortic stenosis
* MR PEYTON MANNING **AS** MVP - systolic * most common * rheumatic fever * **mid systolic, harsh murmur** * **crescendo-decrescendo** * often with mitral regurgitation * audible S4
32
which murmur is louder when squatting?** **and is softer when standing**
* **aortic stenosis** * squatting = increases preload * valsava SHRINKS the ventricles so less blood to pump thru AS = decrease murmur
33
aortic stenosis best heard where?
* Right sternal border/2nd intercostal space * can radiate down L sternal border to apex or up to carotid arteries
34
\*aortic stenosis symptoms
triad: * **a**ngina/chest pain * **c**ongestive heart failure (dyspnea) * **s**yncope - dizziness & exertional, exercise intolerance symptomatic: can be asx until 5-6 decade then rapid deterioration. early recognization of ANY sx and refer asap!
35
\*aortic stenosis diagnostics
* transthoracic 2D ECHO - show thick, calcified immobile AS leaflets * **echo shows cardiomegaly (LATE)** * **_EKG - normal_** with LVH, 1st deg AV block, BBB, * Chest Xray - rounding of L ventricle
36
Aortic stenosis treatment
* if asx → monitor * mod-severe: NO competitive sports, tx risk factors (HTN, HLD w/ ACE) * Stage B or greater: surgery (AVR or TAVR to replace valves or brio prosthetic)
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hypertrophic cardiomyopathy
* peaks mid systole * best heard over L sternal border * **murmur decreased with squatting** * **increases with standing/valsava** * increased murmur with valsalva * S4 present * opposite of AS murmur
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\*aortic regurgitation
* **AR**MS - diastolic murmur * loud blowing HIGH pitched * best heard **Left lower sternal border** * mid systolic ejection murmur in beginning then progresses to diastolic murmur
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\*when is aortic regurgitation heard loudest?
leaning forward post exhale
40
aortic regurgitation sx's
* **asx for 10-15 yrs then acute palpitations, exercise tolerance/SOB at rest** * late:: CHF * “head pounding” * angina * orthopnea/dyspnea * fatigue * paroxysmal nocturnal dyspnea
41
aortic regurgitation treatment
* asx - annual f/u * surgical interventions Stage C or D - goal to intervene before EF \< 50% * treat HTN (CCB/ACE), afib, bradcycardia * refer for post heart Cath
42
\*mitral stenosis
* AR**MS** - diastolic * low pitch, rumbling * opening snap
43
mitral stenosis best heard where and loudest where?
* louder in LEFT lateral recumbent position * best heard at apex
44
\*mitral stenosis symptoms and PE
* most common: **_dyspnea_** * **EKG: atrial fibrillation** * loud S1, apical towards axilla * **CXR - left atrium enlarged** * hemoptysis * R ventricular hypertrophy
45
mitral stenosis functional classes 1-4
* 1: asx * 2: dyspnea great than ordinary exertion * 3: dyspnea less than ordinary exertion * 4: dyspnea minimal exertion, orthopnea, paroxysmal nocturnal dyspnea, PE
46
mitral stenosis treatment
* tx anemia, fluid overload * if sx with exercise - BB or CCB * surgery if stage C or D
47
mitral regurgitation most caused by
mitral valve prolapse
48
\*mitral regurgitation best heard where? what does it sound like?
* at apex, radiates to axilla * PMI displaced downward & to left * holosystolic/pansystolic, harsh/blowing systolic murmur
49
mitral regurgitation sx's
asx for decades then * fatigue, exertional dyspnea, orthopnea * **atrial fibrillation** * **Cxray: L atria/ventricle enlarged** * palpitations, tachycardia * late: R sided HF, PE, LV dysfunction, CHF
50
\*mitral regurgitation treatment
* asx = monitoring at heart valve clinic * **treat underlying causes/sequelae to prevent Left Ventricular dysfunction** * **give BB, ACE/ARB, spironolactone** * **give anticoagulant/warfarin for A Fib to prevent stroke/MI** * consider surgery if asx but LV growing on echo w/o dysfunction
51
mitral valve prolapse risk factors
* causes mitral regurgitation! * usually benign and asx * marfans syndrome, osteogenesis imperfecta, Ehlers danos syndrome
52
\*mitral valve prolapse heard best where and sounds like?
* mid-late systolic **click** (occasional honking) * high pitched murmur * heard best with diaphragm on **apex/Left lower sternal border**
53
MVP sx's
* syncope * palpitations * chest pain * afib * SVT, PVCs - with exercise * EKG normal
54
MVP diagnostics
echo - leaflets blowing 2 mm into atria
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\*MVP treatment
* monitor with ECHO q 3-5 yrs if asymptomatic * treat underlying SVT with **_beta blockers (metoprolol)_** * anticoagulants with atrial fibrillation
56
\*pulmonary stenosis best heard?
* **2nd/3rd intercostal spaces** * **radiates down L sternal border to apex, possible base** * **valsalva increases the murmur** * mid systolic, harsh medium pitched w/ crescendo - descrendo pattern
57
\*pulmonary regurgitation heard best?
* diastolic soft, high pitched descrendo murmur * **heard best at 3rd/4th left intercostal space** * **increases when pt sitting, leaning forward**
58
\*tricuspid stenosis
* less common than mitral stenosis * diastolic, soft, short in duration * heard best 4th or 5th left ICS
59
tricuspid stenosis sx's
* fatigue, lethargy (low CO) * hepatomegaly * ascites, edema * fluttering feeling of discomfort in neck * fluttering * tx: surgical repair
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tricuspid regurgitation
* most commonly d/t R ventricular dilation * often asx, * exertion dyspnea
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7 S's of Innocent Murmurs [normal PE/neg ROS]
* does murmur change with child position or respiration? * short duration (not holosystolic) * single * not with gallop or click * small/not radiating * low amplitude * musical/sweet sound * systolic
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\*\*red flags for murmurs!! REFER!!!!
* holosystolic * diastolic * grade 3 \> * harsh * angina * a/s with congenital defects (marinas, downs) * a/s with additional sounds * **increased intensity with standing/valsalva, decreased with squatting (hypertrophic cardiomyopathy)** * any child less than 1 yrs old
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\*Left to Right shunt defects ACYANOTIC
* Ventricular septal defect (VSD) * Patent ductus arteriosus (PDA) * Atrial septal defect (ASD) * Atrioventricular defect (AVSD)
64
what is the most common congenital heart defect?
ventricular septal defect (VSD)
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ventricular septal defect sx's
* not heard til 2-8 wks old * loud murmur * harsh, high pitched grade 2-4-6 holosystolic murmur at Left lower sternal border * thrill along left sternal border * s/sx CHF * S3 or S4
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VSD Diagnostic
* chest x ray (shows enlargement with Ig shunts) * EKG - normal , maybe LVH * ECHO
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VSD treatment
* small VSD, no CHF monitor q 6 months * larger defects with sx/s CHF: * lanoxin (Digoxin), diuretics, ACE-i, BB * monitor nutrition, weight gain * family teaching about s/sx CHF * surgery/percutaneous device if no improvement * SBE prophylaxis necessary for 6 months after surgery
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\*patent ductus arteriosus
* should close by 1-3 days post birth * aorta-pulmonary artery shunting * L→ R shunt
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**\*\*right to left shunt defects (CYANOTIC)**
blood skipping the lungs * tetralogy of fallot * transportation of great arteries
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**\*\*tricuspid atresia**
* NO tricuspid valve * blind pouch at tricuspid valve * shunts blood from patent foramen ovale (PFO) & ventricular septal defect (VSD) * causes cyanosis, tachycardia, dyspnea * clubbing * tx: IV prostaglandins to keep ductus arterosus, digoxin, diuretics * need surgery in stages
71
**\*\*\*\*atrial fibrillation sx's**
* most common arrhythmia * irregular R-R interval * NO P waves * **fatigue** * **palpitations** * **weakness/dizziness** * **reduced exercise tolerance**
72
which anticoagulant for atrial fib that's good for on the go?
**rivaraoxaban (Xarelto) [taken once daily so easy]** apixaban (eliquis)
73
\*\*\***new onset Afib and symptomatic**
cardiovert! if chronic Afib, NO! (\>1 yr)
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**\*\*\*\*tachyarthrhythmias examples & sx's**
* Atrial fibrillation * ventricular tachycardia (vTach) * supra ventricular tachycardia (SVT) * sx's: palpitations
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tachyarrhytmias triggers
* infection, inflammation, MI, drugs, excess alcohol, * excess caffeine * tobacco * hyperthyroid * catecholamine excess * electrolyte imbalance
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SVT treatment
* bear down, carotid massage * if doesn't work, adenosine, BB, or CCB * if hemodynamically Unstable → cardiovert
533
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