Chapter 51e - Approach to the Patient with Heart Murmur Flashcards Preview

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Flashcards in Chapter 51e - Approach to the Patient with Heart Murmur Deck (70):

What are the mechanisms that might explain a heart murmur?

"Heart murmurs are caused by audible vibrations that are due to the increased turbulence from accelerated blood flow through normal or abnormal orifices, flow through a narrowed or irregular orifice into a dilated vessel or chamber, or backward flow through an incompetent valve, ventricular septal defect, or patent ductus arteriosus."


Continuous murmurs are heard throughout all systole and diastole.
True or False?

"Continuous murmurs are not confined to either phase of the cardiac cycle but instead begin in early systole and proceed through S2 into all or part of diastole."


Which anatomical and functional characteristics dictate the duration and intensity of a heart murmur?

"The duration of a heart murmur depends on the length of time over which a pressure difference exists between two cardiac chambers, the left ventricle and the aorta, the right ventricle and the pulmonary artery, or the great vessels. The magnitude and variability of this pressure difference, coupled with the geometry and compliance of the involved chambers or vessels, dictate the velocity of flow; the degree of turbulence; and the resulting frequency, configuration, and intensity of the murmur."


What is the Gallavardin effect?

This effect usually occurs in the elderly with aortic stenosis, in whom one might hear a heart murmur "higher pitched and more acoustically pure at the apex".
One should distinguish Gallavardin effect from mitral regurgitation, whose heart murmur shares some characteristics.


Mitral valve regurgitation associated with mitral valve prolapse might have an unusual quality as a "honking" sound.
True or False?



How does one explain the higher-pitched aortic valve murmurs comparing to mitral valve murmurs?

The gradient between chambers in aortic valve murmurs is higher comparing to mitral valve murmurs.


A 23-year old patient has a mesosystolic murmur heard in the precordium without irradiation characterized as loud and without a palpable thrill. How do you classify it regarding its intensity?

Grade 3.


Which grade are usually small ventricular septal defects?

Grade 4.


Atrial septal defects usually produces heart murmurs.
True or False?

True and False.
- False: The structural abnormality in itself does not produce any heart murmur, as it is a low-velocity event.
- True: A mid-systolic murmur from "functional" pulmonic stenosis, due to right heart overload, aswell as a mid-diastolic "functional" tricuspid valve stenosis.


A softer murmur is associated with less severe structural heart disease.
True or False?

"Murmurs of grade 3 or greater intensity usually signify important structural heart disease and indicate high blood flow velocit at the site of murmur production."
"The intensity of a heart murmur may be dimished by any process that increases the distance between the intracardiac source and the stethoscope on the chest wall, such as obesity, obstructive lung disease, and a large pericardial effusion. The intensity of a murmur also may be misleadingly soft when cardiac output is reduced significantly or when the pressure gradient between the involved cardiac structures is low."


Which characteristics of a carotid murmur would make you suspect of a more severe condition?

Continuous murmur and palpable thrill.


Name four conditions associated with mitral valve prolapse.

Marfan's syndrome, Ehlers-Danlos syndrome, Straigh-Back syndrome and hyperhyroidism.


Coronary AV fistula, aortic septal defect, anomalous left coronary artery, proximal coronary artery stenosis, pulmonary artery branch stenosis and bronchial collateral circulation include some of the cauyses of continuous murmurs.
True or False?

(other causes include patent ductus arteriousus, ruptured sinus of Valsalva aneurysm, cervical venous hum, mammary souffle of pregnancy, small (restrictive) ASD with MS and intercostal AV fistula)


How does one explain the shorter duration of acute mitral valve regurgitation (MR) in comparison to its chronic disease?

"Acute, severe MR into a normal-sized, relatively noncompliant left atrium results in an early, decrescendo systolic murmur best heard at or just medial to the apical impulse. These characteristics reflect the progressive attenuation of the pressure gradient between the left ventricle and the left atrium during systole owing to the rapid rise in left atrial pressure caused by the sudden volume load into an unprepared, noncompliant chamber and contrast sharply with the auscultatory features of chronic MR."


Which conditions are associated with acute mitral valve regurgation?

Acute myocardial infarction, rupture of chordae tendineae in the setting of myxomatous mitral valve disease, infective endocarditis and blunt chest wall trauma.


How does one distinguish between acute mitral valve regurgitation and ventricular septal rupture following acute myocardial infarction?

"Acute, severe MR from papillary muscle rupture usually accompanies an inferior, posterior, or lateral MI and occurs 2-7 days after presentation. It is often signaled by chest pain, hypotension, and pulmonary edema, but a murmur may be absent in up to 50% of cases. The posteromedial papillary muscle is involved 6 to 10 times more frequently than the anterolateral papillary muscle. The murmur is to be distinguished from that associated with post-MI ventricular septal rupture, which is accompanied by a systolic thrill at the left sternal border in nearly all patients and is holosystolic in duration."
"The disctinction between acute MR and ventricular septal rupture also can be achieved with right heart catheterization, sequential determination of oxygen saturations, and analysis of the pressure waveforms (tall v wave in the pulmonary artery wedge pressure in MR)."


Mitral regurgitation in the context of infective endocarditis is always the result of chordae tendinae rupture.
True or False?

It might be also due to destruction of leaflet tissue.


Blunt thoracic trauma can result in papillary muscle contusion and rupture, chordal detachment, or leaflet avulsion.
True or False?



How does one explain the fact that a small congenital muscular ventricular septal defect (VSD) is characterized by a early systolic murmur and no signs of pulmonary hypertension and congestion whereas a large defect is usually holosystolic and might have pulmonary vascular involvement?

"A congenital, small muscular VSD may be associated with an early systolic muyrmur. The defect closes progressively during septal contraction, and thus, the murmur is confined to early systole."


How come a large ventricular septal defect (VSD) might have a heart murmur that becomes shorter with increasing severity?

"Anatomically large and uncorrected VSDs, which usually involve the membranous portion of the septum (...) associated with the left-to-right shunt, which earlier may have been holosystolic, becomes limited to the first portion of systole as the elevated pulmonary vascular resistance leads to an abrupt rise in right ventricular pressure and an attenuation of the interventricular pressure gradiente during the remainder of the cardiac cycle. In such instances, signs of pulmonary hypertension (right ventricular lift, loud and single or closely split S2) may predominate."


How do you descibre Carvallo's sign?

Incrasing intensity of tricuspid regurgitation murmur.


What is the most common cause of mid-systolic murmur in an adult?

Aortic stenosis.


How does one distinguish between aortic valve stenosis (Gallavardin effect) and mitral regurgitation?

Aortic valve stenosis is associated with a mid-systolic murmur with a late-peak, is graded 3-4, A2 might be decreased or absent, S2 can be paradoxically splitten, and might have S4.
Other features include pulsus parvus et tardus, ECG criteria for left ventricular hypertrophy and ejection sound, mostly on bicuspid noncalcified aortic valves.


Regarding a patient with aortic valve stenosis, an ejection sound is a marker of better prognosis.
True or false?

The presence of ejection sound signifies a flexible, noncalcified bicuspid valve (or one of its variants).


Name the causes of reversed splitting of S2.

Aortic stenosis, myocardial infarction, hypertrophic cardiomyopathy (rarely) and right ventricular pacing.


Obstructive form of hypertrophic cardiomyopathy is usually accompanied with bisferians pulse.
True or False?

Although this pulse is associated with this condition, the carotid pulse is usually normal.


Name the findings in hypertrophic obstructive cardiomyopathy (HOCM).

HOCM is associated with a mid-systolic heart murmur, usually loudest along the left sternal border or between this point and the apex. The intensity of the murmur increases with maneuvers that decrease preload and/or afterload, aswell as medications that increase the inotropism. It usually does not excede grade 3.
Rarely, there might be reversed splitting of S2.
Other features include ECG criteria for left ventricular hypertrophy, S4 and rarely, bisferians pulse.


What is the most common cause of shunting?

Ostum secundum atrial septal defect.


Name the main manifestations of the different atrial septal defects.

Ostium secundum - the most common; fixed splitting of S2 and pulmonic valve "functional" stenosis.
Ostium primum - mitral valve regurgitation and left axis deviation
Sinus venosus - usually not large enough to produce a murmur, but may be assocaited with ECG abnormalities of sinus node


How do you define aortic sclerosis?

"Focal thickening and calcification of the aortic valve to a degree that does not interfere with leaflet opening."


Which conditions might be associated with a grade 1-2 mid-systolic benign murmur?

Aortic sclerosis, pregnancy, hyperthyroidism and anemia, aswell as still's murmur.


What is Still's murmur?

"Still's murmur refers to a benign grade 2, vibratory or musical mid-systolic murmur at the mid or lower left border in normal children and adolescents, best heart in the supine position."


Mitral valve prolapse migh have one or more nonejection clicks associated with heart murmur best heard at the apex.
True or False?



What is the irradation of mitral valve regurgitation?

"With posterior leaflet prolapse or flail, the resultant jet of MR is directed anteriorly and medially, as a result of which the murmur radiates to the base of the heart and masquerades as AS. Anterior leaflet prolapse or flail results in a posteriorly directed MR jet that radiates to the axilla or left infrascapular region."


Pulmonic stenosis of any cause has its murmur prolonged and louder as the stenosis progressively aggravates.
True or False?

(not to be confounded with pulmonic infundibular area obstruction associated with tetralogy of Fallot, in which the murmur will become shorter with progressive disease, since the blood will shunt across the silvent ventricular septal defect)


Which mechanisms explain new systolic murmus in acute myocardial infarction?

- Early Systolic Murmur: acute mitral regurgitation
- Mid-Systolic Murmur: hyperdinamism
- Late Systolic Murmur: "tethering and malcoaptation of the leaflets in response to structural and functional ahcnages of the ventricle and mitral annulus"


Name conditions associated with chronic mitral valve regurgitation.

"Several conditions are associated with chronic MR and an apical holosystolic murmur, including rheumatic scarring of the leaflets, mitral annular calcification, postinfraction left ventricular remodeling, and severe left ventricular chamber enlargement."
"The circumference of the mitral annulus increases as the left ventricle enlarges and leads to failure of leaflet coaptation with central MR in patients with dilated cardiomyopathy."


"MR begets MR". Justify this argument.

"Because the mitral annulus is contiguous with left atrium endocardium, gradual enlargement of the left atrium from chronic MR will result in further stretching of the annulus and more MR"


The abnormal jugular venous waveforms are the predominant finding in tricuspid regurgitation and are seen very often in the absence of an audible murmur despite Doppler echocardiographic verification.
True or False?



Name causes of tricuspid regurgitation.

Primary causes: myxomatous disease (prolapse), endocarditis, rheumatic disease, radiation, carcinoid, Ebstein's anomaly, and chordal detachment as a complication of right ventricular endomyocardial biopsy.
Secondary cause: "TR is more commonly a passive process that results secondarily from annular enlargement due to right ventricular dilatation in the face of volume or pressure overload."


Larger ventricular septal deffects associate with softer holosystolic murmurs than smaller ones.
True or False?

"The intensity of the murmur varies as a function of the anatomic size of the defect. Small, restrictive VSDs, as exemplified by the maladie de Roger, create a very loud murmur (...). With large defects, the ventricular pressures tend to equalize, shunt flow is balanced, and a murmur is not appreciated."


What defines maladie de Roger?

Small, restrictive ventricular septal deffect associated with a very loud holosystolic murmur but without any clinical consequences. These patients have a small increased risk for infective endocarditis.


There are two cardiac phenomenons which are best heard with the patient leaning forward and at expiration. Which ones are they?

Pericardial rub and chronic aortic regurgitation murmur.


How does the irradiation help one identify the etiology of aortic regurgitation?

"With primary valve disease, such as that due to congenital bicuspid disease, prolapse, or endocarditis, the diastolic murmur tends to radiate along the left sternal border, where it is often louder than appreciated in the second right interspace. When AR is caused by aortic root disease, the diastolic murmur may radiate along the right sternal border. Diseases of the aortic root cause dilation or distortion of the aortic annuus and failure of leaflet coaptation. Causes include Marfan syndrome with aneurysm formation, annuloaortic ectasia, ankylosing spondylitis, and aortic dissection."


Grade the intensity of the following murmurs:
(1) Maladie de Roger
(2) Tricuspid Stenosis (due to infective endocarditis)
(3) Hypertrophic Obstructive Cardiomyopathy
(4) Pulmonic "Functional" Stenosis (due to atrial septal defect)
(5) Idiopathic Dillation of the Pulmonic Artery
(6) Aortic Stenosis and other "benign" murmurs
(7) Mitral regurgitation (due to flail)
(8) Austin-Flint murmur

(1) 4-5
(2) 1-2
(3) 3 or less
(4) 2-3
(5) 2-3
(6) 1-2
(7) 3-4
(8) 1-2


Mid-systolic murmur in a patient with known aortic regurgitation (AR) is due to aortic stenosis (AS).
True or False?

True and False.
False: "Although AS and AR may coexist, a grade 2 or 3 crescendo-decrescendo mid-systolic murmur frequently is heard at the base of the heart in patients with isolated, severe AR and s due to an increased volume and rate of systolic flow."
True: "Accurate bedside identification of coexistent AS can be difficult nless the carotid pulse examinatin is abnormal or the mid-systolic murmur is of grade 4 or greater intensity."


Where does one serach for Quincke's pulsations?

At the bed of the nails.


How does one explain the absence of run off signs in acute aortic regurgitation?

The diastolic murmur of acute, severe AR is notably shorter in duration and lower pitched than the murmur of chronic AR. (...) These attributes reflect the abrupt rate of rise of diastolic pressure within the unprepared and noncompliant left ventricle and the correspondingly rapid decline in the aortic-left ventricular diastolic pressure radient."


Acute aortic regurgitation might lead to a soft S1.
True or False?

"Left ventricular diastolic pressure may increase sufficietnly to result in premature closure of the mitral valve and a soft first heart sound."


What is the most common sign of pulmonic regurgitation?

Chronic pulmonary hypertension.


Fallot's tetralogy correction might lead to a softer and lower pitched murmur from pulmonic regurgitation than the classic Graham-Steel murmur.
True or False?

(the severity might be under-appreciated)


Which imaging tests might be useful to document aortic root and proximal ascending aorta disease?

"Transthoracic echocardiography also can provide anatomic information regarding the root and proximal ascending aorta, although computed tomographic or magnetic resonance angiography may be indicated for more precise characterization."


What is the most common cause of mitral stenosis?

Rheumatic fever.


What is the best position to hear a mitral stenosis murmur?

Left lateral decubitus.


As the severity of mitral stenosis aggravates what do you expect to happen to opening snap (OS) and the interval A2-OS (A2 - Aortic valve closure)?

"The interval between the pulmonic component of the second heart sound (P2) [and thus, A2], and the opening snap is inversely related to the magnitude of the left atrial-left ventricular pressure gradient."
Opening snap tends to disappear as the mobility of the mitral valve decreases.


Name two right-sided events that have altered venous jugular waveform.

Tricuspid regurgitation - tall v waves and c-v waves (with increased severity)..
Tricuspid stenosis - prolonged y descent.


How does one name the mid-diastolic murmur associated with an edematous mitral valve during an episode of acute rheumatic?

Carey-Coombs murmur.


How does one explain the mid to late-diastolic murmur associated with complete heart block?

"Complete heart block with dyssynchronous atrial and ventricular activation may be associated with intermittent mid- to late diastolic murmurs if atrial contraction occurs when the mitral valve is partially closed."


If there is a large ductus arteriosus associated with reversed flow (right-to-left shunting), which kind of cyanosis might one observe?

Differential cyanosis (affecting mostly the lower limbs).


The only phenomenon of the intercostal vessels that might explain a continuous murmur is an arteriovenous fistula.
True or False?

"Enchanced flow through enlarged intercostal collateral arteris in patients with aortic coarctation may produce a continuous murmur along the course of one or more ribs."


Where to does a Valsalva sinus rupture to?

Usually right-sided heart chambers.


What are the causes of reversed splitting?

Aortic stenosis, hypertrophic obstructive cardiomyopathy, left bundle branch block, right ventricular pacing or acute myocardial ischemia.


What are the causes of wide S2 splitting?

Premature aortic valve closure (as can occur with severe MR) or delayed pulmonic valve closure (due to pulmonic stenosis or right bundle branch block).


Which left-sided murmurs increase in intensity with maneuvers that increase afterload?

Mitral regurgitation, aortic regurgation and ventricular septal defects.


Name the murmurs that increase in intensity during Valsava maneuver.

Hypertrophic obstructive cardiomyopathy and mitral valve prolapse.


How does one explain the increased aortic stenosis murmur in post-premature ventricular contractrion?

"Systolic murmurs due to left ventricular outflow obstruction, including that due to AS, increase in intensity after a premature beat because of the combined effects on enchanced left ventricular filling and post-extrasystolic potentiation of contractile function."


Every regurgitation detected by echocardiography is clinically significant.
True or False?

"It is importat to note that Doppler signals of trace or mild valvular regurgitation of no clinical consequence can be detected with structurally normal tricuspid, pulmonic, and mitral valves. Such signals are not likely to generate enough turbulence to create an audible murmur."


Name two benign continuous murmurs.

Cervical venous hum and mammary souffle.


What is the rational for serial echocardiography in valvulopathies?

Monitoring the patient and evaluating the increased severity that might determine symptoms, irreversible remodeling and an increase in the risk of intervention/surgery.


What are the advantages and limitations of handheld or miniaturized cardiac ultrasound devices?

"Although several reports attest to the improved sensitivity of such devices for the detection of valvular heart disease, accuracy is higly operator-dependent, and incremental cost considerations and outcomes have not been addressed adequatly."