Cardiac murmurs

Question 1

Explain what ventricular diastole is

Answer 1

Ventricle is RELAXED as blood flows into them from the atria, through the atrioventricular valves

Question 2

explain what ventricular systole is

Answer 2

Ventricle CONTRACTS and pushes blood out through semilunar valves, shutting AV valves

Question 3

Explain what S1 means

Answer 3

S1 = shutting of atrioventricular valves at end of diastole / beginning of systole

Question 4

Explain what S2 means

Answer 4

S2 = shuttiing of semilunar valves at the end of systole, when the blood has been emptied from the ventricles

Question 5

So what is the time period between S1 and S2

Answer 5

systole

Question 6

what is the time period between S2 and S1

Answer 6

diastole

Question 7

So when do the systolic murmurs happen, and what is the single best word to describe them

Answer 7

between S1 and S2
LOUD

Question 8

So when do the diastolic murmurs happen

Answer 8

between S2 and S1

Question 9

what are the systolic murmurs

Answer 9

aortic stenosis (ejection systolic: crescendo-decrescendo) 
mitral regurg (pansystolic)

Question 10

what are diastolic murmurs

Answer 10

aortic regurg (early diastolic) 
mitral stenosis (mid-diastolic)

Question 11

what are causes of aortic stenosis

Answer 11

Calcification (age related)
bicuspid aortic valve
Rheumatic fever

Question 12

symptoms of AS

Answer 12

exertional SAD

• syncope
• angina
• dyspnoea

Question 13

where is AS loudest

Answer 13

2nd ICS at sternal edge

Question 14

what does AS sound like

Answer 14

ejection systolic: crescendo-decrescendo during systole

Question 15

when is AS loudest (time + maneuvr)

Answer 15

• *on EXPIIRATION**
• *pt leaning FORWARD**

Question 16

where does AS radiate to

Answer 16

to CAROTIDS

Question 17

what is apex beat like in AS

Answer 17

forceful, non displaced

Question 18

what is pulse like in AS

Answer 18

• *slow rising**
• *narrow pulse pressure**

Question 19

ix for AS

Answer 19

bedside: ECG (LVH, arrythhmia)

Bloods: FBC (anaemia), U+E, lipids, glucose, BNP (HF)

imaging: CXR (Calcifications, LVH, pulmonary oedema)

Echo (diagnostic)

Coronary angiogram (look for occlusion)

Question 20

mx of AS

Answer 20

MDT

Conservative: lifestyle modification (diet, exercise)

Medical: calculate QRisk (statins, antiplatelets), manage comorb HTN, diabetes etc

if unstable: stablise before surgery = balloon valvuloplasty

Surgical (if sx): open aortic valve replacement (biologic/artificial) or TAVR (transcatheter AV replacement)

Question 21

main ddx of AS

Answer 21

Aortic sclerosis = leaflet thickening without obstruction

• ejection systolic murmur, but does NOT radiate to carotids

Question 22

what does mitral regurg sound like

Answer 22

pansystolic murmur

Question 23

where is MR loudest and how (maneuvres=

Answer 23

loudest on expiration in left lateral position over the apex

Question 24

where does MR radiate to

Answer 24

MR radiates to axill

Question 25

what are causes of MR

Answer 25

Chronic: - **mitral valve prolapse** (leading cause) - **RHD** - **calcification** Acute - **Infective endocarditis** - **Ischaemic heart disease**

Question 26

ix of MR (same for all)

Answer 26

ECG Bloods CXR Echo Coronary angiogram

Question 27

how do you mx MR

Answer 27

MDT approach Conservative: RF modification, regular followup Medical: aim to reduce afterload with ACEi, beta blocker or diuretic Surgical: valve replacement or repair

Question 28

explain how AR occurs

Answer 28

backflow of blood through aortic valve during diastole

Question 29

Causes of AR

Answer 29

50% caused by aortic root dilation (mostly idiopathic…) chronic: * *bicuspid aortic valve** * *RHD** * *CTD** Acute: * *IE** * *Aortic dissection (stanford A)**

Question 30

what does AR sound like

Answer 30

early diastolic murmur loudest at lower left sternal edge

Question 31

what is an austin flint murmur, what is it caused by

Answer 31

**low pitched rumbling mid-diastolic** murmur heard best at the **apex**. Caused by the **regurgitated blood through the aortic valve** mixing with **blood from the left atrium**, during atrial contraction. Sign of **severe aortic regurgitation**.

Question 32

what is pulse pressure like in AS vs AR

Answer 32

AS: narrow AR: wide e.g. 180/50

Question 33

what is the pulse like in AR

Answer 33

waterhammer (collapsing)

Question 34

what is the apex beat like in AR

Answer 34

displaced and thrusting (because LV becomes hypertrophied and dilated)

Question 35

mx of AR

Answer 35

same as MR MDT approach Conservative = lifestyle mod Medical = aim to reduce afterload (ACEi, BB, diuretic) Surgical = valve replacement

Question 36

what condition is MR and MS associated with

Answer 36

AF -- because MR and MS cause left atrial enlargement, which increases risk of AF

Question 37

what facial feature occurs with MS

Answer 37

malar flush

Question 38

what does MS murmur sound like

Answer 38

mid diastolic murmur

Question 39

whee aand how is MS best heard

Answer 39

in left lateral position with bell at end expiration

Question 40

which murmur is associated with AF

Answer 40

Mitral regurgitation or mitral stenosis

Question 41

causes of MS

Answer 41

RHD \> include benzylpen prophylaxis in your management