heart murmurs

Question 1

What does aortic stenosis refer to?

Answer 1

tightening of the aortic valve at the origin of the aorta

Question 2

What is aortic stenosis associated with?

Answer 2

An ejection systolic murmur heard loudest over the aortic valve

Question 3

what is the aortic stenosis murmur described as having?

Answer 3

Crescendo-decrescendo quality

Question 4

where does the aortic stenosis murmur commonly radiate to?

Answer 4

Carotid arteries

Question 5

What are the causes of aortic stenosis?

Answer 5

Calcification of the aortic valves

Congenital abnormality of the aortic valve

Rheumatic heart disease

Question 6

What can be done to accentuate an aortic stenosis murmur?

Answer 6

Ask patient to lean forward, and breath out, hold breath - this is when this murmur can be heard loudest

Question 7

What are some of the other clinical features of aortic stenosis?

Answer 7

Slow rising pulse with narrow pulse pressure

Non-displaced, heaving apex beat (if present indicates left ventricular hypertrophy)

Reduced or absent S2 (a 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)

Question 8

When does mitral regurgitation occur?

Answer 8

When there is backflow of blood from the left ventricle into the left atria during ventricular systole.

Question 9

What is mitral regurgitation associated with?

Answer 9

a pansystolic murmur heard loudest over the mitral area

Question 10

Where does mitral regurgitation murmur radiate too?

Answer 10

axilla

Question 11

What are the causes of mitral regurgitation?

Answer 11

Infective endocarditis

Acute myocardial infarction with rupture of papillary muscles

Rheumatic heart disease

Congenital defects of the mitral valve

Cardiomyopathy

Question 12

When is mitral regurgitation heard loudest

Answer 12

on expiration in the left lateral decubitus position

Question 13

What are some other clinical features of mitral regurgitation?

Answer 13

Displaced, hyperdynamic apex beat

Question 14

When does aortic regurgitation occur?

Answer 14

when there is a backflow of blood from the aorta into the left ventricle during ventricular diastole

Question 15

What is aortic regurgitation associated with?

Answer 15

early diastolic murmur heard loudest at the left sternal edge

Question 16

What are diseases affecting the valve that can cause AR?

Answer 16

Congenital bicuspid aortic valve

Rheumatic heart disease

Infective endocarditis

Question 17

What are causes of aortic root dilatation that results in AR?

Answer 17

Aortic dissection: can result in acute aortic regurgitation

Connective tissue diseases (e.g. Marfan’s syndrome)

Aortitis

Question 18

What is the Austin flint murmur?

Answer 18

a low pitched rumbling mid-diastolic murmur heard best at the apex. This is caused by the regurgitated blood through the aortic valve mixing with blood from the left atrium, during atrial contraction.

Question 19

What is the Austin flint murmur a sign of?

Answer 19

Severe aortic regurgitation

Question 20

What are some other clinical features of AR?

Answer 20

collapsing pulse

displaced hyperdynamic apex beat

Question 21

What does mitral stenosis involve and what does this cause?

Answer 21

narrowing of the mitral valve, which results in decreased filling of the left ventricle during systole and increased left atrial pressure

Question 22

What is mitral stenosis associated with?

Answer 22

a low-pitched, rumbling, mid-diastolic murmur heard loudest over the apex

Question 23

What is the most common cause of mitral stenosis?

Answer 23

Rheumatic heart disease

Question 24

What are other causes of mitral stenosis?

Answer 24

Congenital

Left atrial myxoma

Connective tissue disorders

Mucopolysaccharidosis

Question 25

What are typical clinical features of mitral stenosis?

Answer 25

Low-pitched, rumbling mid-diastolic murmur with an opening click (click heard in mid-diastole when the mitral valve opens) Murmur is heard loudest over the apex Loudest in left lateral decubitus position on expiration

Question 26

What are other clinical features of mitral stenosis?

Answer 26

A low-volume pulse which may be irregularly, irregular Loud first heart sound with tapping apex beat A malar flush (plum-red discolouration of the cheeks)

Question 27

When does a mitral valve prolapse occur?

Answer 27

mitral valve leaflets prolapse into the left atrium during systole

Question 28

What is mitral valve prolapse associated with?

Answer 28

a combination of a mid-systolic click and mid to late-systolic murmur

Question 29

What are the typical features of mitral valve prolapse murmur?

Answer 29

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

Question 30

When does a tricuspid regurgitation murmur occur?

Answer 30

when there is the backflow of blood from the right ventricle into the right atrium during ventricular systole

Question 31

What does tricuspid regurgitation cause?

Answer 31

an increase in right atrial pressure and elevated venous pressures

Question 32

What is tricuspid regurgitation associated with?

Answer 32

a pansystolic murmur heard loudest over the tricuspid region

Question 33

What are causes tricuspid regurgitation?

Answer 33

Right ventricular dilatation (e.g. secondary to pulmonary stenosis or pulmonary hypertension) Rheumatic fever Infective endocarditis (intravenous drug users are at high risk of endocarditis affecting the tricuspid valve) Carcinoid syndrome Congenital (e.g. atrial septal defect, Ebstein anomaly)

Question 34

What is the Ebstein anomaly?

Answer 34

abnormal attachment of tricuspid valve leaflets which causes the tricuspid valve to displace downwards into the right ventricle.

Question 35

What are typical clinical features of a tricuspid regurgitation murmur?

Answer 35

Pansystolic murmur Heard loudest over the tricuspid region Loudest during inspiration

Question 36

What are other clinical features of tricuspid regurgitation?

Answer 36

Large ‘v-waves’ visible in the jugular veins: 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

Question 37

What does pulmonary stenosis refer too?

Answer 37

the narrowing of the pulmonary valve

Question 38

What are causes of pulmonary stenosis?

Answer 38

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

Question 39

What are typical features of a pulmonary stenosis murmur?

Answer 39

Ejection systolic murmur heard loudest over pulmonary area Loudest during inspiration Radiates to left shoulder/left infraclavicular region In severe pulmonary stenosis, the murmur is longer and may obscure the sound of A2

Question 40

What are other clinical features of pulmonary stenosis?

Answer 40

Prominent ‘a waves’ in the jugular veins 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 P2 may be soft and inaudible Right ventricular dilatation can lead to a right ventricular heave, tricuspid regurgitation and peripheral signs of right-sided heart failure

Question 41

When does pulmonary regurgitation occur?

Answer 41

backflow of blood from the pulmonary artery into the right ventricle during ventricular diastole

Question 42

What are causes of pulmonary regurgitation?

Answer 42

Pulmonary hypertension Infective endocarditis Congenital valvular heart disease

Question 43

T/F - Pulmonary regurgitations are usually asymptomatic?

Answer 43

True

Question 44

What are typical features of a pulmonary regurgitation murmur?

Answer 44

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

Question 45

What does tricuspid stenosis refer to?

Answer 45

narrowing of the tricuspid valve

Question 46

What is tricuspid stenosis associated with?

Answer 46

a soft diastolic murmur heard loudest at 3rd – 4th intercostal space at the left sternal edge

Question 47

What are causes of tricuspid stenosis?

Answer 47

heumatic fever (most common) Congenital disease Infective endocarditis

Question 48

What are typical clinical features of a tricuspid stenosis murmur?

Answer 48

Mid-diastolic murmur (rarely audible) Loudest at 3rd – 4th intercostal space at the left sternal edge Loudest during inspiration

Question 49

What are other clinical features of Tricuspid stenosis?

Answer 49

Raised JVP with giant ‘a waves’ | Peripheral oedema, ascites

Question 50

Which murmurs are heard loudest on expiration?

Answer 50

``` Aortic stenosis Mitral regurgitation Mitral Valve prolapse Aortic regurgitation Mitral stenosis ```

Question 51

Which murmurs are heard loudest on inspiration?

Answer 51

Pulmonary stenosis Tricuspid regurgitation Pulmonary regurgitation Tricuspid stenosis

Question 52

Which are systolic murmurs?

Answer 52

``` Aortic stenosis pulmonary stenosis Mitral regurgitation Tricuspid regurgitation Mitral valve prolapse ```

Question 53

Which are the diastolic murmurs?

Answer 53

Aortic regurgitation Pulmonary regurgitation Mitral stenosis Tricuspid stenosis