Data interpretation: Heart murmurs

Question 1

How do you explain to a patient what a heart murmur is?

Answer 1

Extra sound in your heartbeat, which occurs when blood doesn’t flow smoothly through your heart

Question 2

How do you explain to a patient what causes heart murmurs?

Answer 2

In your heart, there are 4 chambers. For blood to flow from chamber to chamber, it must pass through valves (act as gates)

Normally, blood flows smoothly through the valves and so when you listen to the heartbeat, it will sound like a normal ‘lub dub’

If blood isn’t flowing smoothly past the valves, this produces an extra sound that is called a heart murmur

Question 3

Where do you auscultate for each of the 4 heart valves?

Answer 3

1. Palpate carotid pulse at the same time, as this is S1/’lub’ (start of systole and end of diastole)
2. Auscultate with diaphragm of stethoscope
3. Aortic valve: 2nd ICS, right sternal edge
4. Pulmonary valve: 2nd ICS, left sternal edge
5. Tricuspid valve: 4th/5th ICS, left sternal edge
6. Mitral valve: 5th ICS, mid-clavicular line

Question 4

When you hear a heart murmur, how do you describe it?

Answer 4

Use SCRIPT mnemonic:

S – Site: where is the murmur loudest?
C – Character: soft / blowing / crescendo (getting louder) / decrescendo (getting quieter) / crescendo-decrescendo (louder then quieter)
R – Radiation: can you hear the murmur over the carotids (aortic stenosis) or left axilla (mitral regurgitation)?
I – Intensity: what grade is the murmur?
P – Pitch: is it high-pitched or low and rumbling? Pitch indicates velocity.
T – Timing: is it systolic or diastolic?

Question 5

What is the S1/’lub’ heart sound?

Answer 5

Beginning of ventricular systole (ventricles start to contract and pump blood out of heart)

‘Lub’: Closing of the mitral and tricuspid valves to prevent backflow of blood, as ventricular pressure is greater than atrial pressure

Occurs at the same time as carotid pulse

Question 6

Why does S1/lub heart sound occur at the same time as the carotid pulse?

Answer 6

Because its beginning of ventricular systole

So ventricles contract and pump blood into the aorta and pulmonary artery

Blood being pushed into aorta creates palpable carotid pulse, as common carotid artery branches directly off aorta

Question 7

Where is S1/lub auscultated loudest in the heart and why?

Answer 7

Near apex

This is where mitral and tricuspid valves are located

Question 8

What is the delay between S1/lub and S2/dub heart sounds?

Answer 8

Ventricular systole: Ventricles are currently contracting and pumping blood out of heart into aorta and pulmonary arteries

Question 9

What is S2/dub heart sound?

Answer 9

Beginning of atrial systole (atria start to contract and pump blood into ventricles)
——————————————
‘dub’: Closing of the aortic and pulmonary valves to prevent backflow of blood into ventricles, as pressure is now lower in the ventricles

Question 10

Where is S2/dub auscultated loudest in the heart and why?

Answer 10

Base (top) of heart

This is where aortic and pulmonary valves are located

Question 11

What occurs in the time from S2 to S1 of the next cardiac cycle?

Answer 11

Ventricular diastole: Ventricles are currently relaxed and filling with blood

Atrial systole: Atria are currently pumping blood into ventricles

Question 12

What is meant by a systolic murmur, and how do you recognise it?

Answer 12

A murmur that is heard between S1/lub and S2/dub (during systole)

Has a rushing sound, and the murmur starts when you feel a carotid pulsation

Question 13

What is meant by a diastolic murmur, and how do you recognise it?

Answer 13

A murmur that is heard between S2/dub and S1/lub (during diastole)

Has a whooshing sound, and the murmur and carotid pulsation alternate

Question 14

How do you explain to a patient what aortic stenosis is?

Answer 14

The aorta is the biggest blood vessel in the body, and it comes directly off the heart’s main pumping chamber (left ventricle). Blood has to pass through the aortic valve to enter the aorta.

Aortic stenosis is when the aortic valve becomes narrowed.

This reduces blood flow to the rest of the body, and causes turbulent flow in the heart as blood is struggling to get past the narrowing

Question 15

How do you explain to a patient what can cause aortic stenosis?

Answer 15

Born with bicuspid valve instead of tricuspid valve

Age-related calcification and stiffening

Infections: IE, rheumatic fever

Autoimmune conditions: Lupus, RA

Inherited conditions: Paget’s disease, hypercholesterolemia

Genetic conditions: Marfans

Question 16

How do you explain to a patient the 5 symptoms of aortic stenosis?

Answer 16

Syncope upon exertion

Angina: Chest pain that occurs due to activity and is relieved by rest

Shortness of breath, orthopnea, PND

Fatigue

Narrow pulse pressure

Question 17

If a patient has aortic stenosis, what type of murmur will they have and why?

Answer 17

Ejection systolic murmur

Systolic: Because it occurs during systole when the ventricles are trying to pump blood through the faulty aortic valve

Ejection systolic: Because it only occurs during ventricular contraction and not beginning or end, so S1 and S2 are clearly audible

Question 18

Describe the 4 main features of the ejection systolic murmur caused by aortic stenosis?

Answer 18

Crescendo-decrescendo character: Grows louder then softer

Distinct S1/lub, then murmur, then distinct S2/dub

Louder on expiration

Severe AS: Ejection systolic murmur radiates to carotid

Question 19

If a patient has an ejection systolic murmur from aortic stenosis, what accentuation maneuver should you do?

Answer 19

Ask patient to hold their breath then use diaphragm to auscultate carotids for ejection systolic murmur

Question 20

What are the 3 definitive treatment options for aortic stenosis?

Answer 20

Aortic Valve Replacement (AVR)/repair: Severe AS with symptoms or reduced LV function

• Surgical AVR (SAVR): Preferred in low surgical risk patients, as it is an open heart surgery to insert prosthetic valve (metal or animal tissue)
• Transcatheter AVR (TAVI/TAVR): For older or high-risk patients, as valve is inserted via catheter in leg

Balloon valvuloplasty Rare; for young adults or as a bridge in unstable patients, as valve is opened up by balloon catheter

Question 21

How do you explain to a patient what aortic regurgitation is?

Answer 21

The aorta is the biggest blood vessel in the body, and it comes directly off the heart’s main pumping chamber (left ventricle). Blood has to pass through the aortic valve to enter the aorta.

Aortic regurgitation is when the aortic valve doesn’t close properly.

This causes backflow of blood into the heart again, and less is pumped out to the rest of the body

Question 22

How do you explain to a patient what can cause aortic regurgitation? CREAM

Answer 22

C: Congenital heart defects eg. bicuspid aortic valve
R: Rheumatic damage eg. Rheumatic fever, SLE, RA, Takayasu arteritis, Crohn’s, AxSpa
E: Endocarditis
A: Aortic dissection or aortic root dilation (functional/secondary regurgitation which causes stretched valve ring, so cusps don’t meet and valve can’t close)
M: Marfan’s syndrome

Question 23

How do you explain to a patient the 5 symptoms of aortic regurgitation?

Answer 23

Breathlessness upon exertion

Angina: Chest pain that occurs due to activity and is relieved by rest

Palpitations

Fatigue

Wide pulse pressure and water-hammer pulse

Question 24

If a patient has aortic regurgitation, what kind of murmur will they have and why?

Answer 24

Early diastolic murmur

Diastolic: Because it occurs during diastole when the aortic valve should be closed to prevent backflow into ventricles, just after blood has entered aorta

Early diastolic: Starts immediately after S2/dub because the backflow of blood begins as soon as the aortic valve leaflets are no longer supported by the pressure in the aorta

Question 25

Describe the 3 features of the early diastolic murmur caused by aortic regurgitation?

Answer 25

Decrescendo shape: Starts loud then gets softer Distinct S1/lub, distinct S2/dub then murmur, then S1 again Louder on expiration

Question 26

If a patient has an early diastolic murmur from aortic regurgitation, what accentuation maneuver should you do?

Answer 26

Ask patient to lean forwards, take a deep breath in and out then hold it, then use diaphragm to auscultate aortic region for early diastolic murmur

Question 27

What are the 2 definitive treatment options for aortic regurgitation?

Answer 27

Aortic Valve Replacement (AVR)/repair: Severe AR with symptoms or reduced LV function - Surgical AVR (SAVR): Preferred in low surgical risk patients, as it is an open heart surgery to insert prosthetic valve (metal or animal tissue) - Transcatheter AVR (TAVI/TAVR): For older or high-risk patients, as valve is inserted via catheter in leg

Question 28

How do you explain to a patient what mitral stenosis is?

Answer 28

Mitral valve is the opening that separates 2 of the heart chambers on the left side: The left atrium and left ventricle. The main function of the mitral valve is to open to let blood flow from left atrium into left ventricle, and to prevent backflow Mitral stenosis is when the mitral valve becomes narrowed

Question 29

How do you explain to a patient the causes of mitral stenosis? CREDIT

Answer 29

C: Congenital heart defects R: Rheumatic damage eg. Rheumatic fever, SLE, RA, Takayasu arteritis, Crohn’s, AxSpa E: Endocarditis D: Degenerative calcification I: Inflammation (carcinoid syndrome) T: Therapy (radiation)

Question 30

How do you explain to a patient the 4 symptoms of mitral stenosis?

Answer 30

Malar flush: Plum rash that spares nasolabial folds Haemoptysis: Coughing up blood Breathlessness on exertion, PND, orthopnea Palpitations (due to strong association with AF: increased pressure and volume overload in the left atrium, caused by the narrowed mitral valve, triggers structural and electrical changes in the atrial tissue, making it prone to irregular electrical activity)

Question 31

If a patient has an mid-diastolic murmur from mitral stenosis, what accentuation maneuver should you do?

Answer 31

Ask patient to lie on their left side then take a deep breath in and out then hold it, then use bell to auscultate mitral area for mid-diastolic murmur, then auscultate into axilla

Question 32

What murmur is caused by mitral stenosis, and why?

Answer 32

Mid-diastolic rumbling murmur with opening snap Diastolic: Because it occurs during diastole, as this is also atrial systole so atrium should be pumping blood through mitral valve Mid-diastolic: Because it only occurs during ventricular filling and not beginning or end

Question 33

Describe the 4 features of the mid-diastolic murmur caused by mitral stenosis?

Answer 33

Rumbling character with low pitch Louder on expiration Opening snap: High-pitched sound heard after S2, due to abrupt tensing of the mitral valve leaflets as they open in early diastole, often due to the valve leaflets being thickened or fused, which is a common finding in mitral stenosis Distinct S1, distinct S2 then opening snap and mid-diastolic mumur, then distinct S1 again

Question 34

What are the 3 definitive treatment options for mitral stenosis?

Answer 34

Percutaneous mitral balloon valvotomy: Balloon catheter inserted through leg to open mitral valve, preferred for non-calcified rheumatic fever/symptomatic MS and high-risk patients Mitral valve replacement/repair: - Surgical: Preferred in low surgical risk patients, as it is an open heart surgery to insert prosthetic valve (metal or animal tissue) - Transcatheter: For older or high-risk patients, as valve is inserted via catheter in leg

Question 35

If a patient has an pansystolic murmur from mitral regurgitation, what accentuation maneuver should you do?

Answer 35

Ask patient to lie on their left side then take a deep breath in and out then hold it, then use diaphragm to auscultate mitral area for pansystolic murmur, then auscultate into axilla

Question 36

How do you explain to a patient what mitral regurgitation is?

Answer 36

The mitral valve is the opening between the 2 heart chambers on the left side, the left atrium and the left ventricle. The mitral valve normally opens and closes to let blood flow from the left ventricle to the left atrium, and closes to prevent back flow. Mitral regurgitation is when the mitral valve doesn't close properly, so blood leaks back into left atrium, and less is pumped around the rest of the body

Question 37

How do you explain to a patient the causes of mitral regurgitation?

Answer 37

Congenital defects Ischaemic mitral regurgitation: heart attack can injure the heart muscle, including the papillary muscles and chordae tendineae (tendon-like cords) that support the mitral valve Rheumatic fever Autoimmune and collagen vascular diseases

Question 38

How do explain to a patient the symptoms of mitral regurgitation?

Answer 38

Breathlessness on exertion, pulmonary edema (dry cough) Orthopnea, PND Palpitations (due to strong association with AF: increased pressure and volume overload in the left atrium, caused by the narrowed mitral valve, triggers structural and electrical changes in the atrial tissue, making it prone to irregular electrical activity) Fatigue

Question 39

What murmur is caused by mitral regurgitation and why?

Answer 39

Pansystolic murmur Systolic: Occurs when ventricles are pumping blood out so mitral valve should be fully closed to prevent backflow Pansystolic: Occurs throughout beginning, middle, end of systole

Question 40

Describe the 3 features of the pansystolic murmur caused by mitral regurgitation?

Answer 40

High-pitched, blowing character Louder on expiration Can still hear S1 S2 or be obscured

Question 41

What are the definitive treatment options for mitral regurgitation?

Answer 41

Mitral valve replacement/repair: - Surgical: Preferred in low surgical risk patients, as it is an open heart surgery to insert prosthetic valve (metal or animal tissue) - Transcatheter: For older or high-risk patients, as valve is inserted via catheter in leg

Question 42

What are the 4 right-sided heart murmurs?

Answer 42

Pulmonary stenosis Tricuspid stenosis Pulmonary regurgitation Tricuspid stenosis

Question 43

How do you explain to a patient what pulmonary stenosis is?

Answer 43

The pulmonary trunk is a blood vessel that comes directly off the heart's main pumping chamber (left ventricle). Blood has to pass through the pulmonary valve to enter the pulmonary trunk, then this blood travels to the lungs. Pulmonary stenosis is when the pulmonary valve becomes narrowed. This reduces blood flow to the rest of the lungs, and causes turbulent flow in the heart as blood is struggling to get past the narrowing

Question 44

How do you explain to a patient what pulmonary regurgitation is?

Answer 44

The pulmonary trunk is a blood vessel that comes directly off the heart's main pumping chamber (left ventricle). Blood has to pass through the pulmonary valve to enter the pulmonary trunk, then this blood travels to the lungs. Pulmonary regurgitation is when the pulmonary valve doesn't close properly, so there is backflow into heart

Question 45

How do you explain to a patient what tricuspid stenosis is?

Answer 45

Tricuspid valve is the opening that separates 2 of the heart chambers on the right side: The right atrium and right ventricle. The main function of the tricuspid valve is to open to let blood flow from right atrium into right ventricle, and to prevent backflow Tricuspid stenosis is when the tricuspid valve becomes narrowed

Question 46

How do you explain to a patient what tricuspid regurgitation is?

Answer 46

Tricuspid valve is the opening that separates 2 of the heart chambers on the right side: The right atrium and right ventricle. The main function of the tricuspid valve is to open to let blood flow from right atrium into right ventricle, and to prevent backflow Tricuspid regurgitation is when the tricuspid valve doesn't close properly, so there is backflow into right atrium

Question 47

What are the 2 most common right-sided heart valve diseases, and what murmurs do these cause?

Answer 47

Pulmonary stenosis: Ejection systolic murmur that radiates to left 2nd ICS Tricuspid regurgitation: Pansystolic murmur

Question 48

How do you explain to a patient the causes of right-sided heart murmurs?

Answer 48

Congenital defects Rhematic fever Left-sided heart failure

Question 49

What murmur is caused by pulmonary regurgitation?

Answer 49

Early-diastolic murmur

Question 50

What murmur is caused by tricuspid stenosis?

Answer 50

Mid-diastolic murmur

Question 51

How do you explain to a patient the symptoms of right-sided murmurs?

Answer 51

Shortness of breath, persistent cough Right-sided heart failure: Ankle edema, ascites, pulsatile liver, abdominal pain and bloating, raised JVP Cyanosis

Question 52

To confirm a right-sided murmur, what accentuation maneuver should you do?

Answer 52

Ask patient to take a deep breath in and hold it

Question 53

What are the 3 definitive treatments for right-sided murmurs?

Answer 53

Balloon valvotomy Valve repair/replacement

Question 54

Why are left-sided murmurs louder on expiration?

Answer 54

Expanded lung parenchyma collapsing and the pooled volume of blood in it being squeezed into the left side of the heart

Question 55

Why are right-sided murmurs louder on inspiration?

Answer 55

When inhaling, a more negative intra-thoracic pressure is created. This increases venous return to the right ventricle

Question 56

How often do patients have echo monitoring for valve disease?

Answer 56

Mild AR: Echo every 2–3 years Moderate: Echo annually Severe: (asymptomatic, normal LV): Echo every 6–12 months

Question 57

What is the main benefit and disadvantage of a metal valve in valve replacement?

Answer 57

More durable and only needs replacement every 20-30 years Need lifelong warfarin due to risk of blood clots

Question 58

What is the main benefit and disadvantage of a animal valve in valve replacement?

Answer 58

Don't need lifelong warfarin Less durable, needs to be replaced every 10-15 years