Cardio - Murmurs

Question 1

What valve diseases can cause cardiac hypertrophy?

Answer 1

Aortic Stenosis

Mitral stenosis

Question 2

What valve diseases can lead to cardiac dilatation?

Answer 2

Mitral regurgitation

Aortic Regurgitation

Question 3

When would S3 be heard and what can indicate?

Answer 3

S3 can be heard roughly 0.1s after S2 and in young patients it can be physiologically normal.
In elderly patients it may be a sign of heart failure

Question 4

When would you hear S4?

Answer 4

A fourth heart sound would be heard directly before S1.

Question 5

What causes S4?

Answer 5

Always abnormal and very rare
Stiff or hypertrophied ventricle.
It is caused by turbulent flow from the atria

Question 6

Give some causes of mitral stenosis:

Answer 6

Infective endocarditis

Rheumatic fever

Question 7

What valve disease would you expect in a mid diastolic low pitched rumbling murmur?

Answer 7

Mitral Stenosis

Question 8

Give some other signs and symptoms of mitral stenosis:

Answer 8

Malar flush
Atrial fibrillation
Loud S1
Tapping apex beat

Question 9

What valve disease would cause a high pitched, pan systolic murmur that radiates to the left axilla?

Answer 9

Mitral Regurgitation

Question 10

List some causes of mitral regurgitation:

Answer 10

Marfans
Ehler Danlos syndrome
Ischaemic heart disease
Rheumatic fever
Infective endocarditis
Idiopathic age related weakening

Question 11

What heart condition can result from mitral regurgiation?

Answer 11

Congestive heart failure

Question 12

What other signs may be seen with mitral regurgitation?

Answer 12

S3
Reduced ejection fraction
Radiates to the axilla
“whistling” murmur

Question 13

What is the most common valve disease you will come acorss?

Answer 13

Aortic stenosis

Question 14

What valve disease would cause an ejection systolic murmur which is high pitched and has a crescendo-decrescendo character?

Answer 14

Aortic stenosis

Question 15

What other symptoms and signs may be seen in a patient with aortic stenosis?

Answer 15

Radiating murmur to the carotids
Slow rising pulse
Narrow pressure pule
Exertional Syncope

Question 16

What are the main causes of aortic stenosis?

Answer 16

Rheumatic heart disease
idiopathic
Age related calcification

Question 17

What valve disease would cause an early diastolic, soft murmur?

Answer 17

Aortic regurgitation

Question 18

What is Corrigan’s pulse/ corrigans sign? What valve disease is this associated with?

Answer 18

This is a collapsing pulse and pulsations of the carotids. It is associated with aortic regurgitation (insufficiency)

Question 19

What is an Austin flint murmur?

Answer 19

This is an early diastolic rumbling murmur best heard at the apex. Caused by aortic regurgitation

Question 20

What are some causes of Aortic regurgitation?

Answer 20

Idiopathic
Age related weakness
Connective tissue diseases

Question 21

What is a pro and con of mechanical heart valves?

Answer 21

Pro - they have a long lifespan of >/20 years

Con - require lifelong warfarin anti coagulation

Question 22

What is the ideal INR for patients on warfarin?

Answer 22

2.5-3.5

Question 23

What is the typical lifespan of a bio prosthetic valve?

Answer 23

Roughly 10 years.

Question 24

What are the main risks of a mechanical heart valve?

Answer 24

Thrombus
Infective endocarditis
Haemolysis leading to haemolytic anaemia

Question 25

Define TAVI:

Answer 25

Transcatheter Aortic Valve Implantation

Question 26

When might a TAVI procedure be more appropriate?

Answer 26

Treatment for severe aortic stenosis - especially in high risk patients who would not be suitable for an open procedure

Question 27

What % of patients who undergo valve replacements end up with infective endocarditis?

Answer 27

2.5%

Question 28

What are the main causative organisms for infective endocarditis?

Answer 28

Staphylococcus Aureus Streptococcus Viridans Streptococcus

Question 29

What are some other signs and symptoms of aortic regurgitation?

Answer 29

``` Wide pulse pressure Large volume collapsing pulse Capillary bed pulsations (Quinke's sign) Pistol shots over the arteries Head nodding in time with pulse ```

Question 30

What is the deMusset sign?

Answer 30

This is when the head nods along in time with the patient's pulse and is seen in aortic regurgitation

Question 31

What type of valve disease would you expect in a blowing pan-systolic murmur best heard at the left lower sternal edge during inspiration, accompanied with a raised JVP?

Answer 31

Tricuspid regurgitation

Question 32

What valve disease is often associated with carcinoid syndrome and may be congenital?

Answer 32

Pulmonary stenosis | Tricuspid stenosis is also seen more rarely in carcinoid syndrome

Question 33

What valve disease would you expect in a patient with a harsh, mid-systolic ejection murmur best heard in the left upper sternal border, 2nd intercostal space, accompanied by a 4th heart sound, thrill and a right ventricular heave?

Answer 33

Pulmonary stenosis

Question 34

A patient presents with left parasternal heave, wide fixed splitting of the 2nd heart sound and a mid systolic murmur best heard at the left sternal edge -- what is the most likely cause?

Answer 34

Atrial septal defect

Question 35

Patient presents with a loud/harsh pan-systolic murmur, cyanosis and clubbing, along with symptoms of dyspnoea chest pain and syncope? What is the most likely diagnosis?

Answer 35

Ventricular septal defect

Question 36

If you see a child in the "squatting position" trying to help themselves breath, what congenital heart problem may they suffer from?

Answer 36

Tetralogy of Fallot

Question 37

What is Erb's point?

Answer 37

This is the best place for listening to heart sounds S1 and S2. It is located in the 3rd intercostal space at the left sternal border.

Question 38

What valve disease would you expect in a mid diastolic, rumbling murmur best heard at the left lower sternal edge, made louder by inspiration?

Answer 38

Tricuspid stenosis

Question 39

What valve disease would cause a decrescendo, diastolic murmur?

Answer 39

Pulmonary regurgitation Very hard to distinguish between aortic regurgitation but usually asymptomatic patient

Question 40

What heart condition will lead to a continuous machinery murmur best heard below the left clavicle in the first intercostal space, and is often accompanied with a thrill?

Answer 40

Patent ductus arteriosis

Question 41

What heart condition will cause a mid to late systolic murmur best heard over the upper precordium or the back which may be accompanied by vascular bruits?

Answer 41

Coartication of the aorta

Question 42

What finding during a paediatric baby check is suggestive of aortic coartication?

Answer 42

Radiofemoral delay with a difference in pre and post ductal saturation

Question 43

What is the cut off aortic gradient for aortic valve stenosis valve repair?

Answer 43

40mmHg

Question 44

In patients with critical aortic stenosis who are not fit for an valve replacement, what is the next most suitable management option?

Answer 44

Aortic balloon valvuloplasty

Question 45

What investigation is often done in patients with aortic stenosis before a valve replacement and why?

Answer 45

Coronary angiogram | To look for co-existing cardiovascular disease

Question 46

In pulmonary hypertension, what would be heard on auscultation?

Answer 46

Loud Second heart sound

Question 47

What is the most common cause of mitral stenosis?

Answer 47

Rheumatic fever