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533 > Week 6 Heart Murmurs > Flashcards

Week 6 Heart Murmurs Flashcards

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
Q

*valvular heart disease complications

A
  • 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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26
Q

NP role in VHD

A
  • 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
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27
Q

Systolic murmurs

A

MR. Peyton Manning AS MVP

  • Mitral regurgitation
  • physiological murmur
  • aortic stenosis
  • mitral valve prolapse
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28
Q

diastolic murmurs

A

ARMS

  • aortic regurgitation
  • Mitral Stenosis
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29
Q

steps to find a murmur

A
  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
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30
Q

aortic stenosis etiologies

A
  • 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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31
Q

*aortic stenosis

A
  • MR PEYTON MANNING AS MVP - systolic
  • most common
  • rheumatic fever
  • mid systolic, harsh murmur
  • crescendo-decrescendo
  • often with mitral regurgitation
  • audible S4
32
Q

which murmur is louder when squatting?**

and is softer when standing

A
  • aortic stenosis
    • squatting = increases preload
  • valsava SHRINKS the ventricles so less blood to pump thru AS = decrease murmur
33
Q

aortic stenosis best heard where?

A
  • Right sternal border/2nd intercostal space
  • can radiate down L sternal border to apex or up to carotid arteries
34
Q

*aortic stenosis symptoms

A

triad:

  • angina/chest pain
  • congestive heart failure (dyspnea)
  • syncope - dizziness & exertional, exercise intolerance

symptomatic: can be asx until 5-6 decade then rapid deterioration. early recognization of ANY sx and refer asap!

35
Q

*aortic stenosis diagnostics

A
  • 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
Q

Aortic stenosis treatment

A
  • 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)
37
Q

hypertrophic cardiomyopathy

A
  • 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
38
Q

*aortic regurgitation

A
  • ARMS - diastolic murmur
  • loud blowing HIGH pitched
  • best heard Left lower sternal border
  • mid systolic ejection murmur in beginning then progresses to diastolic murmur
39
Q

*when is aortic regurgitation heard loudest?

A

leaning forward post exhale

40
Q

aortic regurgitation sx’s

A
  • 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
Q

aortic regurgitation treatment

A
  • 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
Q

*mitral stenosis

A
  • ARMS - diastolic
  • low pitch, rumbling
    • opening snap
43
Q

mitral stenosis best heard where and loudest where?

A
  • louder in LEFT lateral recumbent position
  • best heard at apex
44
Q

*mitral stenosis symptoms and PE

A
  • most common: dyspnea
    • EKG: atrial fibrillation
  • loud S1, apical towards axilla
  • CXR - left atrium enlarged
  • hemoptysis
  • R ventricular hypertrophy
45
Q

mitral stenosis functional classes 1-4

A
  • 1: asx
  • 2: dyspnea great than ordinary exertion
  • 3: dyspnea less than ordinary exertion
  • 4: dyspnea minimal exertion, orthopnea, paroxysmal nocturnal dyspnea, PE
46
Q

mitral stenosis treatment

A
  • tx anemia, fluid overload
  • if sx with exercise - BB or CCB
  • surgery if stage C or D
47
Q

mitral regurgitation most caused by

A

mitral valve prolapse

48
Q

*mitral regurgitation best heard where? what does it sound like?

A
  • at apex, radiates to axilla
    • PMI displaced downward & to left
  • holosystolic/pansystolic, harsh/blowing systolic murmur
49
Q

mitral regurgitation sx’s

A

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
Q

*mitral regurgitation treatment

A
  • 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
Q

mitral valve prolapse risk factors

A
  • causes mitral regurgitation!
  • usually benign and asx
  • marfans syndrome, osteogenesis imperfecta, Ehlers danos syndrome
52
Q

*mitral valve prolapse heard best where and sounds like?

A
  • mid-late systolic click (occasional honking)
  • high pitched murmur
  • heard best with diaphragm on apex/Left lower sternal border
53
Q

MVP sx’s

A
  • syncope
  • palpitations
  • chest pain
  • afib
  • SVT, PVCs - with exercise
  • EKG normal
54
Q

MVP diagnostics

A

echo - leaflets blowing 2 mm into atria

55
Q

*MVP treatment

A
  • monitor with ECHO q 3-5 yrs if asymptomatic
  • treat underlying SVT with beta blockers (metoprolol)
  • anticoagulants with atrial fibrillation
56
Q

*pulmonary stenosis best heard?

A
  • 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
Q

*pulmonary regurgitation heard best?

A
  • diastolic soft, high pitched descrendo murmur
  • heard best at 3rd/4th left intercostal space
  • increases when pt sitting, leaning forward
58
Q

*tricuspid stenosis

A
  • less common than mitral stenosis
  • diastolic, soft, short in duration
  • heard best 4th or 5th left ICS
59
Q

tricuspid stenosis sx’s

A
  • fatigue, lethargy (low CO)
  • hepatomegaly
  • ascites, edema
  • fluttering feeling of discomfort in neck
  • fluttering
  • tx: surgical repair
60
Q

tricuspid regurgitation

A
  • most commonly d/t R ventricular dilation
  • often asx,
  • exertion dyspnea
61
Q

7 S’s of Innocent Murmurs [normal PE/neg ROS]

A
  • 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
62
Q

**red flags for murmurs!! REFER!!!!

A
  • 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
63
Q

*Left to Right shunt defects ACYANOTIC

A
  • Ventricular septal defect (VSD)
  • Patent ductus arteriosus (PDA)
  • Atrial septal defect (ASD)
  • Atrioventricular defect (AVSD)
64
Q

what is the most common congenital heart defect?

A

ventricular septal defect (VSD)

65
Q

ventricular septal defect sx’s

A
  • 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
66
Q

VSD Diagnostic

A
  • chest x ray (shows enlargement with Ig shunts)
  • EKG - normal , maybe LVH
  • ECHO
67
Q

VSD treatment

A
  • 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
68
Q

*patent ductus arteriosus

A
  • should close by 1-3 days post birth
  • aorta-pulmonary artery shunting
  • L→ R shunt
69
Q

**right to left shunt defects (CYANOTIC)

A

blood skipping the lungs

  • tetralogy of fallot
  • transportation of great arteries
70
Q

**tricuspid atresia

A
  • 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
Q

****atrial fibrillation sx’s

A
  • most common arrhythmia
  • irregular R-R interval
  • NO P waves
  • fatigue
  • palpitations
  • weakness/dizziness
  • reduced exercise tolerance
72
Q

which anticoagulant for atrial fib that’s good for on the go?

A

rivaraoxaban (Xarelto) [taken once daily so easy]

apixaban (eliquis)

73
Q

***new onset Afib and symptomatic

A

cardiovert!

if chronic Afib, NO! (>1 yr)

74
Q

****tachyarthrhythmias examples & sx’s

A
  • Atrial fibrillation
  • ventricular tachycardia (vTach)
  • supra ventricular tachycardia (SVT)
  • sx’s: palpitations
75
Q

tachyarrhytmias triggers

A
  • infection, inflammation, MI, drugs, excess alcohol,
  • excess caffeine
  • tobacco
  • hyperthyroid
  • catecholamine excess
  • electrolyte imbalance
76
Q

SVT treatment

A
  • bear down, carotid massage
  • if doesn’t work, adenosine, BB, or CCB
  • if hemodynamically Unstable → cardiovert

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