1. Rheu-mitral (rheumatic cardiac disease) 2. Radiates to Axilla (regurgitates to armpit) 3. Best heard at Apex (it's closer to axilla) 4. Holosystolic (plateau) 5. Loud/blowing S1 lower than S2... since valve doesn't fully close.. usually higher

Cardiac Lecture - Stewart Flashcards by Tafadzwa Amani

Aortic stenosis presentations

OLD valves are SAD : Syncope, Angina, Dyspnea
Crescendo-Decrescendo (letter A)
Calcified aortic valve
Radiates UP to Carotids
Increased intensity with Squatting Valsalva
Decreased intensity Standing Valsalva

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major cause of Tricuspid Regurgitation

associated type of murmur

TRIscuspid hit the most by IV drugs (venous- TRI Drugs)

2. Holosystolic/pansystolic/plateau murmur (continuos throughout systole)

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Aortic Regurgitation characteristics

Early blowing diastolic murmur
Connective tissue disorders
Marfan Syndrome
Head-blobbing
Femoral Bruits (backwash->turbulence)
Water-Hammer Pulse

ARR, there she blows early!

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pathology and location of systolic ejection murmur

heard during systole at the apex of heart (5th ICS on MCL).
Mitral valve Regurgitation

murmur due to blood going to where it’s not supposed to go (backflow)

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Mitral Stenosis Pathology

Opening Snap (soon after S2, during distal as ventricle begins to fill)
Rheumatic fever history (Rheumitral)
OS is MS

opening snap is Mitral stenosis

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Mitral Valve Prolapse (MVP)

midsystolic-click to S2 (crescendo)
young woman with psychiatric issues (anxiety)
Myxematous (tumor) Valvular Pathology (MVP)

the MVP clicks in the Mid-dle of nowhere!!

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pathology of systolic murmur

mitral regurgitation

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Mitral Regurgitation

Rheu-mitral (rheumatic cardiac disease)
Radiates to Axilla (regurgitates to armpit)
Best heard at Apex (it’s closer to axilla)
Holosystolic (plateau)
Loud/blowing

S1 lower than S2… since valve doesn’t fully close.. usually higher

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effect of inspiration on murmur

louder Right heart side murmur (T&P loud)
increases preload
increases intrathoracic pressure

R-In

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effect of expiration on murmur

Left heart louder (M&A) (L-expiration)

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increase in preload on aortic murmur in HOCM

decreases aortic murmur

more blood volume and pressure push the ventricular septum away from the aortic outflow allowing blood to move easily

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decrease in preload on aortic murmur in HOCM

increases aortic murmur

less blood to push septum away from outflow track thus an obstruction and disruption of blood flow

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increased preload in MVP

improves mid-systolic click

allows the prolapsed valve leaflets to return to their normal orientation

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MVP valves orientation under normal pressure

mitral valve leaflets prolapse into L. atria under normal pressure and cause a disruption in blood flow

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HOCM pathophysiology

type of murmur

Loud aortic murmur
small left ventricle due to thickened left ventricular septum

septum underwent hypertrophy to increase workload

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MVP pathophysiology under normal pressure

-blood leaks back into left atrium due to mitral valve prolapse under normal pressure

MVP with regurgitation

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HOCM presentation

intensity of murmur with squat and standing valsalva

family history of sudden cardiac death at a young age

louder with decreased preload and afterload (stand)
softer with increased preload and afterload (squat)

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4 possible causes of systolic murmurs

Aortic stenosis
Pulmonary stenosis
Mitral regurgitation
Tricuspid regurgitation

+ HJR (Hepatic Jugular Reflux)

poorly compliant RV, RV failure (failing to stretch so blood backflows easily)
constrictive pericarditis
obstructive RV filling due to RA tumor/ TS

+VE: Blood builds up in jugular and is visible as they distend and pulsate for a longer time

distension disappears sooner in a healthy heart –> heart increases outflow in response to increased blood volume

cause of Increased JVP

SVC obstruction
severe heart failure
constrictive pericarditis, cardiac tamponade, RV infarction

V wave

Atrial filling / ventricular contraction

increasing volume and pressure and RA when TV is closed

prominent V wave could mean

TR (backflow of blood into atria increases pressure)

- pulm hypertension (increase RA due to back-pressure)

A wave

R. Atrial Contraction, TV opens. coincides with S1, precedes carotid pulsation

Giant A wave

obstruction between RV AND RA (TV stenosis, RA myxoma)
Increased RV pressure (pulmonary stenosis)
recurrent pulm emboli
pulmonary hypertension
A-V dissociation (complete heart block, Ventricular Tachycardia)….(cannon a waves ) - RA contracts against the closed TV… In normal cases, Ventricle and A contraction shld be 1 after the other allowing TV to close and open but as long as there is no communication btwn the 2, there is continuous contraction on both ends while TV is closed

c wave

backwash push by closure of TV during isovolumetric systole and by impact of carotid artery adjacent to JV

X WAVE AND STEEP X WAVE

x-wave: passive atrial filling and atrial relaxation. blood flows into the RA from the cava and TV is closed steep x: caridiac tamponade , constrictive pericarditis... making heart chamber unable to fully comply/stretch

y wave deep Y CAUSE slow Y

rapid ventricular filling - open TV --RV diastole ``` deep Y (low Y pressure): severe TR slow: obstruction to RV filling (TS/ RA myxoma) ```

left atria fills the stiff, non-compliant left ventricle under high pressure (LIKE trying to fill and already full ventricle)...more like applying brakes --- failing ventricle pathologic over 40 but physiologic in young chn/ young adults Ken-Tuck-Y

Ten-Nes-See atrial filling sound due to high pressure from SVC/IVC and pulm venous return Hypotension, CAD, old infarction normal in athelets

loudest point of S1 and S2

S1: at the apex ...Mitral valve (L.5th ICS at MCL) S2: at the base (Aortic valve) right 2nd ICS at sternal border remember base of heart is at the top S1 marks beginning of systole s2: end

splitting of S2 happens during

Inspiration (physiologic) due to increased VR during insp. and more time need for rv to deliver blood to the lung --delayed P2/p-closure

Tricuspid valve location

L. 4th ICS at L. Sternal Border

what grade do you start hearing thrills

grade 4-6

4 points to check pitting for edema

Behind medial malleolus dorsum of foot anterior tibia (shin) sacrum

blunted diaphragms in a chest x-ray indicates

effusion

cause of pansystolic murmur on right and left

right VSD Tricuspid regurg left mitral valve regurg

cause of mid-late diastolic murmur (right and left)

right: ASD Tricuspid stenosis ``` left: mitral stenosis (presystolic crescendo) ```

left sternal border early diastolic murmur

aortic/pulmonic regurg

continuous murmurs

congenital and clinical conditions (not necessarily uniform but murmur is heard all the time)

Ebb's point is best place to hear which murmur

aortic regurgitation - soft, high-pitched, early diastolic decrescendo (btwn pulmonic and mitral valve)

best position to listen to AR and MS

AR: seated and leaning forward (ebb's point) MS: left lateral decubitus (apex, PMI , BELOW NIPPLE ) - belly of stetho

Late Systolic Murmur patient

healthy. non-pathological

Diastolic vs systolic murmur grades

diastolic - 4 systolic 6 both are easily heard at 3 no thrills in diastole