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303 - Medicine > Cardio - Heart murmurs > Flashcards

Cardio - Heart murmurs Flashcards

1
Q

Causes of heart murmurs

A
  • Blood flowing through an abnormal narrowing(eg aortic stenosis, mitral stenosis, pulmonary stenosis)
  • Blood flowing in the wrong direction through the heart, and mixing with blood flowing in the normal direction(eg mitral regurg, tricuspid regurg)
  • An abnormal connection between two different parts of the heart(eg atrial septal defect, patent ductus arteriosus). Blood flows across this abnormal connection –> 1. mixing of blood going in different directions 2. Too much blood flowing into another heart chamber
  • Blood flowing faster through the heart(functional murmurs in sepsis and thyrotoxicosis)
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2
Q

Transmitted heart murmurs

A
  • Aortic stenosis radiates to the carotid arteries

- Mitral regurg - radiates to the axilla

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3
Q

Systole

A
  1. Ventricles contract
  2. Aortic and pulmonary valves open to allow blood to flow through - narrowing of either the aortic or pulmonary valve causes a systolic murmur
  3. Mitral and tricuspid valves close shut to prevent blood flowing backwards through these valves - backwards flow of blood(regurg) through the mitral or tricuspid valves causes a systolic murmur
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4
Q

Diastole

A
  1. Ventricles and atria relax at the start of diastole (early diastole)
  2. Aortic and pulmonary valves shut to prevent blood from flowing backwards through these valves - abnormal backflow of blood through the aortic or pulmonary valves causes an early diastolic murmur
  3. Atria contract towards the end of diastole(mid or late-diastole)
  4. Mitral and tricuspid valves open to allow blood flow to ventricles - narrowing of mitral or tricuspid valve causes a mid, late or end-systolic murmur
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5
Q

S1

A
  • Caused by the closure of the mitral and tricuspid valves
  • Denotes the start of systole
  • Peripheral pulse will be felt at the same time or just after S1
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6
Q

S2

A
  • Caused by the closure of the aortic and pulmonary valves
  • Denotes the end of systole and start of diastole
  • The pulmonary valve may close just after the aortic valve:
    • Closure of the pulmonary valve just after the aortic valve is prolonged during inspiration, or in defects which cause more blood to be pumped out of the right ventricle
    • Therefore S2 may not always be heard as one discrete sound but may be muffled or have two discrete sounds
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7
Q

Systolic murmurs

A
  • Aortic and pulmonary stenosis
  • Mitral and tricuspid regurg
  • Mitral valve prolapse gives a systolic murmur with an opening click
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8
Q

Early diastole murmur

A
  • Aortic and pulmonary regurg
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9
Q

Mid/late-diastole

A
  • Mitral and tricuspid stenosis
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10
Q

Characteristics of systolic murmurs

A

Aortic and pulmonary stenosis - ejection systolic(crescendo-decrescendo)

Mitral and tricuspid regurgitation - pansystolic

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11
Q

Other causes of ejection systolic murmurs

A
  • Aortic sclerosis and hypertrophic obstructive cardiomyopathy (HOCM)
  • Atrial septal defects and pulmonary stenosis
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12
Q

Murmurs heard loudest with diaphragm

A

High pitched murmurs

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13
Q

Murmurs heard loudest with bell

A

Low pitched murmurs (eg mitral regurg)

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14
Q

Aortic area

A

2nd intercostal space right sternal edge

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15
Q

Pulmonary area

A

2nd intercostal space left sternal edge

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16
Q

Tricuspid area

A

4th intercostal space left sternal edge

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17
Q

Mitral area

A

Cardiac apex (usually 5th intercostal space in the left midclavicular line)

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18
Q

Manoeuvre to exaggerate aortic valve murmur

A

Sitting forward brings the aortic valve closer to the chest wall, thus aortic murmurs are heard louder while sitting forward

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19
Q

Manoeuvre to exaggerate mitral valve murmur

A

Left lateral decubitus position Brings the apex closer to the chest wall, thus mitral valve murmurs are heard loudest in this position

20
Q

Murmurs heard loudest on inspiration

A

Intrathoracic pressure reduces, so more blood flows into the right heart chambers
Right-sided valve lesions (pulmonary and tricuspid valves) are heard loudest during inspiration

21
Q

Murmurs heard loudest on expiration

A

Expiration
Intrathoracic pressure increases, forcing pulmonary vessels to constrict, so blood is forced from pulmonary veins into the left atrium and through the left side of the heart
Left-sided heart valve lesions (aortic and mitral valves) are heard loudest during expiration

22
Q

Where does aortic regurg murmur radiate to

A
  • Radiates to the left sternal edge(usually heard best at the left sternal edge and not in the aortic valve region)
23
Q

Where does pulmonary stenosis murmur radiate to

A
  • To the left shoulder/infra-clavicular region
24
Q

Aortic stenosis description

A
  • Ejection systolic murmur
  • Slow rising pulse with narrow pulse pressure
  • Non-displaced, heaving apex beat(if present indicates LVH)
  • Reduced or absent S2(sign of moderate-severe aortic stenosis)
  • Reverse splitting of S2 - aortic valve closes after pulmonary valve(due to the longer time required for blood to exit the left ventricle)
25
Q

Causes of aortic stenosis

A
  • Degenerative age-related calcification(commonest cause)

- Bicuspid aortic valve(important cause in a young person with aortic stenosis)

26
Q

Mitral regurg description

A

Pansystolic murmur
Heard loudest over mitral area
Radiates to axilla
Heard loudest using the bell of the stethoscope
Loudest on expiration in the left lateral decubitus position
Displaced, hyperdynamic apex beat

27
Q

Causes of mitral regurg

A 
Degenerative
Left ventricular dilatation (the space between the left atrium and ventricle becomes dilated meaning the mitral valve is no longer able to close this gap)
Ruptured chordae tendinae
Papillary muscle rupture
Rheumatic heart disease
Infective endocarditis
Mitral valve prolapse
Connective tissue disease e.g. Marfan syndrome, Ehlers-Danlos syndrome
28
Q

What causes the characteristic collapsing pulse in aortic regurg

A

After ventricular systole, the aortic valve closes to prevent blood from flowing back into the left ventricle from the aorta
In aortic regurgitation, blood flows back/regurgitates into the left ventricle after ventricular systole
This causes a sudden, abrupt drop in blood pressure after ventricular contraction, and thus a sudden drop in arterial pressure with a subsequent collapse of arterial vessel walls

29
Q

Description of aortic regurg

A

Decrescendo early diastolic murmur
Heard loudest at left sternal edge (the direction that turbulent blood flows) – sometimes heard loudest over the aortic area
Collapsing pulse (i.e. water hammer pulse with wide pulse pressure)
Displaced, hyperdynamic apex beat
Austin Flint murmur (sign of severe aortic regurgitation) – 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.

30
Q

Causes of aortic regurg

A

Ascending aortic arch dissection
Infective endocarditis
Chest trauma
Prosthetic aortic valve failure
Connective tissue disease (e.g. Marfan syndrome, Ehlers-Danlos syndrome)
Rheumatological disorders
Seronegative spondyloarthropathies (e.g. ankylosing spondylitis)
Takayasu arteritis, rheumatoid arthritis, SLE
Syphilis

31
Q

What does mitral stenosis sound like

A

A ‘snapping sound’ ie. opening click when the mitral valve opens
Mitral valve closes against high left atrial pressure, causing a loud S1 and a tapping apex beat (ie. a palpable closing mitral valve)

32
Q

What might be present in mitral stenosis

A

Signs of pulmonary hypertension may be present:

  • Malar flush
  • Right sternal heave
  • Graham steel murmur - early decrescendo murmur heard in the pulmonary area due to pulmonary incompetence
33
Q

Mitral stenosis description

A

Low-pitched, rumbling mid-diastolic murmur with an opening click (click heard in mid-diastole when the mitral valve opens)
Heard loudest over the apex
Loudest in left lateral decubitus position on expiration
Low-volume pulse which may be irregularly, irregular (atrial fibrillation is common in mitral stenosis)
Loud first heart sound with tapping apex beat (due to a palpable closing of the mitral valve)

34
Q

Causes of a mitral stenosis murmur

A 
Rheumatic heart disease (commonest cause of mitral stenosis worldwide)
Congenital
Left atrial myxoma
Connective tissue disorders
Mucopolysaccharidosis
35
Q

Mitral valve prolapse description

A

Mid-systolic click (prolapse of the mitral valve into left atrium)
Followed by a mid or late-systolic murmur
Heard loudest at the apex
Loudest in expiration

36
Q

Mitral valve prolapse causes

A

The most common valvular abnormality (prevalence is about 5%).

Can occur alone, or in association with:

Rheumatic heart disease
Connective tissue disorders – Marfan syndrome, Ehlers Danlos syndrome, osteogenesis imperfecta
Ebstein anomaly
Associated with an atrial septal defect and patent ductus arteriosus
Systemic lupus erythematosus

37
Q

Why does tricuspid regurg cause elevated venous pressures

A

Tricuspid regurgitation causes blood to flow from the right ventricle to right atrium during ventricular systole. This causes an increase in right atrial pressure and hence elevated venous pressures.

38
Q

Tricuspid regurg description

A 
Pansystolic murmur
Heard loudest over the tricuspid region
Loudest during inspiration
Large ‘v-waves’ in JVP – caused by the right atrial filling of blood against a closed tricuspid valve
Visible/palpable hepatic pulsations
Signs of right-sided heart failure:
Right ventricular heave
Peripheral oedema
Hepatomegaly
Ascites
39
Q

Tricuspid regurg causes

A

Right ventricular dilatation (e.g. secondary to pulmonary stenosis or pulmonary hypertension)
Rheumatic fever
Infective endocarditis (IV drug users are at high risk of endocarditis affecting the tricuspid valve)
Carcinoid syndrome
Congenital (e.g. atrial septal defect, AV canal, Ebstein anomaly)
Ebstein anomaly i.e. congenital isolated tricuspid regurgitation –abnormal attachment of tricuspid valve leaflets causes the tricuspid valve to displace downwards into the right ventricle

40
Q

Pulmonary stenosis typical description

A

Ejection systolic murmur
Heard loudest over pulmonary area
Loudest during inspiration
Radiates to left shoulder/ left infraclavicular region
Prominent ‘a waves’ in JVP
Widely split S2 – blood from the ventricles takes longer to pass through a narrow pulmonary valve, so pulmonary valve closure occurs much later than aortic valve closure

41
Q

What might pulmonary stenosis sound like in severe cases

A

In severe pulmonary stenosis, the murmur is longer and may obscure the sound of A2
P2 may be soft and inaudible
Right ventricular dilatation can lead to:
Right ventricular heave
Tricuspid regurgitation
Peripheral signs of right-sided heart failure (e.g. peripheral oedema, ascites etc)

42
Q

Causes of pulmonary stenosis

A

Congenital
Turner’s, Noonan’s and Williams syndromes
Tetralogy of Fallot – pulmonary stenosis, right ventricular hypertrophy, ventricular septal defect and overriding aorta
Rheumatic fever
Carcinoid syndrome

43
Q

Pulmonary regurg typical description

A

Early decrescendo murmur
Heard loudest over the left sternal edge
Loudest during inspiration
Usually due to pulmonary hypertension – known as a Graham Steell murmur when associated with mitral stenosis

44
Q

Tricuspid stenosis description

A 
Mid-diastolic murmur (rarely audible)
Loudest at 3rd-4th intercostal space, left sternal edge
Loudest during inspiration
Signs of right atrial enlargement
Raised JVP with giant ‘a waves’
Peripheral oedema, ascites
45
Q

Causes of tricuspid stenosis

A
  • Rheumatic fever(most common)
  • Congenital disease
  • infective endocarditis

303 - Medicine (10 decks)

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