Heart Murmurs

Question 1

what causes 1st heart sound (S1)

Answer 1

Closing of the atrioventricular valves - triscupid + mitral valves

• this is start of systole

Question 2

what causes 2nd heart sound (S2)

Answer 2

closing of semilunar valves - pulmonary + aortic

• this is start of diastole

Question 3

what does a 3rd heart sound indicate in

• a young healthy person (15- 40 years)
• older patient

Answer 3

normal in young, healthy individuals

3rd heart sound heard in HF in older individuals

Question 4

what causes a 4th heart sound?

Answer 4

turbulent blood flow against a stiff/ hypertrophic ventricle

• heard directly before S1
• always pathological

Question 5

most common heart murmur

Answer 5

aortic stenosis

Question 6

triad of symptoms in aortic stenosis

Answer 6

syncope, angina, dyspnoea on exertion

Question 7

what type of murmur is aortic stenosis

Answer 7

ejection systolic murmur

Question 8

where is aortic stenosis best heard? where does it radiate to?

Answer 8

aortic area, radiates to carotids

Question 9

what causes aortic stenosis in the elderly?

Answer 9

degenerative calcification

Question 10

what causes aortic stenosis in younger patients? <65 years

Answer 10

congenital bicuspid valve

Question 11

slow rising pulse + narrow pulse pressure is seen with which heart murmur

Answer 11

aortic stenosis

Question 12

what might happen to the heart sounds in aortic stenosis

Answer 12

quiet S2

may have 4th heart sound

Question 13

what investigation is definitive for valvular disease

Answer 13

echo- transthoracic or trans oesophageal

Question 14

management of aortic stenosis if asymptomatic

Answer 14

observe + modify cardiac risk factors 6 monthly echo

Question 15

management of aortic stenosis if severe + symptomatic and fit for surgery

Answer 15

surgical aortic valve replacement (SAVR)

• mechanical valve: last longer but require anti-coagulation
• bioprosthesis: fail sooner but only require 3 months aspirin

Question 16

management of aortic stenosis if severe + symptomatic but not fit for surgery

Answer 16

TAVI (transcatheter aortic valve implantation)

Balloon valvuloplasty - temporary relief (6-12 months), used as bridge to TAVI in unstable patients

Question 17

summary of symptoms / signs in aortic stenosis

Answer 17

ejection systolic murmur

symptoms: chest pain, dyspnoea, syncope

narrow pulse pressure

slow rising pulse

soft / abscent S2

Question 18

features of aortic regurgitation

Answer 18

early diastolic murmur best heart at apex

collapsing pulse

wide pulse pressure

Question 19

causes of aortic regurgitation

Answer 19

idiopathic age related weakness

connective tissue disorders e.g. Ehlers Danlos, Marfans

Question 20

mid diastolic rumbling murmur with loud S1 ‘ opening snap’

Answer 20

mitral stenosis

Question 21

what causes mitral stenosis

Answer 21

rheumatic fever

Question 22

which murmur has a tapping apex beat

Answer 22

mitral stenosis

Question 23

features of mitral stenosis

Answer 23

mid diastolic rumbling murmur

loud S1, ‘opening snap’

tapping apex beat

malar flush

AF

Question 24

pansystolic blowing murmur that radiates to axilla

Answer 24

mitral regurgitation

Question 25

causes of mitral regurgitation

Answer 25

weakening of valve with age ischaemic heart disease infective endocarditis rhuematic heart disease ehlers danlos / marfans

Question 26

what murmurs can be ejection systolic

Answer 26

aortic stenosis pulmonary stenosis

Question 27

what murmurs can be pansystolic

Answer 27

mitral regurgitation tricuspid regurgitation

Question 28

which murmur is associated with AF

Answer 28

Mitral stenosis