Heart Murmurs and Congenital Heart Disease - Dolphens Flashcards Preview

Adult/Ped Medicine 4 > Heart Murmurs and Congenital Heart Disease - Dolphens > Flashcards

Flashcards in Heart Murmurs and Congenital Heart Disease - Dolphens Deck (17):
1

Coarctation of Aorta

 

Review specific heart disease that present as a murmur in children, including: Coarctation

  • Systolic ejection murmur in midback, also LUSB
  • May have continuous murmur in back (older)
  • Increased BP in arms
  • Lower BP with weak to absent pulses in legs
  • LV heave
  • RVH (infant) or LVH (older) on EKG
  • May have cardiomegaly, abnormal aortic contour, or rib notching on CXR

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2

Aortic Stenosis

 

Describe the common adult heart murmurs associated with AS, AR, MS, and MR.

  • most common fatal valvular heart lesion
  • cause: degenerative calcification
  • age: typically 60+
  • long latent period prior to symptoms

symptoms (prognosis):

  • angina (5 years)
  • syncope (3 years)
  • heart failure (2 years)

harsh, mid-systolic ejection murmur

best heard: aortic area

diagnostic studies

  • ECG: LVH, LBBB
  • CXR: aortic valve calcification
  • Echo: determine LV dimensions, pressure gradient, estimate valve area and ejection fraction

tx: valve replacement

 

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3

Mitral Regurgitation

 

Describe the common adult heart murmurs associated with AS, AR, MS, and MR.

Causes

  • mitral vavle prolapse
  • ischemic heart disease
  • cardiomyopathy
  • infective endocarditis
  • connective tissue disorders
  • congenital defect
  • trauma

Chronic

  • asymptomatic
  • fatigue and mild dyspnea on exertion
  • progresses to DOE, PND, PE, hemoptysis

Acute

  • symptomatic
  • LHF - DOE, PND, pulmonary congestion, cardiogenic shock

Murmur

  • holosystolic
  • blowing
  • heard at apex, radiates to axilla
  • no changes in intensity

Diagnostics

  • ECG: LA enlargment, LV/RV hypertrophy
  • CXR: LA and LV enlargment
  • Echo: confirms dx, chamber dimensions, LA/LV function

Management

  • ACE inhibitors
  • surgery in symptomatic patient, EF below 50%

3

Small Ventricular Septal Defect

 

Review specific heart disease that present as a murmur in children, including: VSD

  • most common form of CHD
  • typically close by 1 year
  • inverse relationship with newborns age
  • no SBE prophylaxis

Murmur

  • High-pitched Holosystolic murmur @ LMSB to LLSB
  • May or may not have a thrill
  • Generally no LV heave or RV lift
  • Normal S2
  • No diastolic murmur
  • Normal EKG and chest x-ray

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4

Large Ventricular Septal Defect

 

Review specific heart disease that present as a murmur in children, including: VSD

  • perimembranous or membranous
  • pulmonary overcirculation
  • often require surgical closure 4-6 months

Murmur

  • Low pitched Holosystolic murmur @ LMSB to LLSB
  • Diastolic flow rumble @ apex
  • Increased precordial activity
  • Increased P2 intensity
  • May have RVH +/- LVH on EKG
  • May have cardiomegaly and pulmonary plethora on x-ray

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4

Atrial Septal Defect

 

Review specific heart disease that present as a murmur in children, including: ASD

  • usually asymptomatic - no murmur
  • rSR' pattern on EKG
  • recommend closure when large or RA and RV enlargment
  • no SBE prophylaxis

Murmur

  • Systolic ejection murmur @ LUSB
  • Diastolic flow rumble @ LLSB
  • No palpable thrill
  • RV heave
  • Fixed Split S2
  • May have RVH on EKG
  • May have cardiomegaly and pulmonary plethora on x-ray

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6

Innocent Murmurs: Pulmonary Branch Murmur of Infancy

 

Describe the evaluation of heart murmurs in children, being able to differentiate between pathologic and innocent murmurs: branch pulmonary stenosis

Timing: Systolic ejection

Intensity: 1-3/6

Location: LUSB, RUSB, to axillae and back

Pitch: Medium

Character: Blowing

Helpful Maneuvers:  None

8

Innocent Murmurs: Venous Hum

 

Describe the evaluation of heart murmurs in children, being able to differentiate between pathologic and innocent murmurs: venous hum

 

Timing: Continuous

Intensity: 1-3/6

Location: RUSB, occasionally LUSB

Pitch: Medium

Character: Machinery-like

Helpful Maneuvers:  Supine to sitting, Head position, Compression of jugular vein

 

9

Innocent Murmurs: Pulmonary Flow Murmur

 

Describe the evaluation of heart murmurs in children, being able to differentiate between pathologic and innocent murmurs: pulmonary flow murmur

Timing: Systolic ejection

Intensity: 1-3/6

Location: LUSB

Pitch: Low to medium

Character: Blowing

Helpful Maneuvers:  Inspiration, Standing

9

Aortic Stenosis

 

Review specific heart disease that present as a murmur in children, including:  Aortic Stenosis

  • Bicuspid Aortic Valve
  • No SBE prophylaxis

Murmur

  • Systolic ejection murmur @ RUSB to Neck
  • May have thrill @ RUSB or SSN
  • Usually with ejection click
  • May have LV heave
  • May have assoc diastolic murmur if valve leaks
  • May have LVH on EKG
  • May have cardiomegaly, or prominent aortic shadow  on x-ray

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10

Aortic Regurgitation

 

Describe the common adult heart murmurs associated with AS, AR, MS, and MR.

Chronic - asymptomatic for decades

  • degnerative disorders
  • dilation of ascending aorta
  • bicuspid aortic valve
  • rheumatic fever
  • syphilis
  • connective tissue disorder

Acute - develop LV failure abruptly resulting in symptoms

  • aortic dissection
  • infective endocarditis
  • trauma
  • valve rupture
  • hypertension

high frequency blowing decrescendo diastolic murmur along LSB

high pulse pressure

echo: valve morphology, LV dimension, aortic root size, ejection fraction

tx: surgery when ejection fraction below 55%

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11

Mitral Disease

 

  • require ACE inhibitor and anti-arrhythmic
  • no SBE prophylaxis

Murmur

  • Non-ejection Click, Late Systolic Murmur
  • May have Diastolic Rumble @ Apex
  • May have of Palpitations, Arrhythmias,
  • Chest Pain
  • May have Nonspecific ST-T Wave Changes
  • May have Cardiomegaly on CXR
  • May have LVH or LAE on EKG
  • Marfan, Ehlers-Danlos, Stickler’s, Fragile X, Connective Tissue Syndromes

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12

Diagnostic Criteria for Innocent Murmur

 

Understand how to identify innocent vs. pathologic murmurs murmurs

  • classic findings for a specific innocent murmur
    • grade 1/2, changes with position, LLSB
  • no history/complaints to suggest disease
  • no additional physical findings to suggest disease

13

Mitral Stenosis

 

Describe the common adult heart murmurs associated with AS, AR, MS, and MR.

sequela of rheumatic heart disease develops years-decades after rheumatic fever

clinical features:

  • chronic fatigue - low cardiac output
  • decreased exercise tolerance
  • SOB
  • orthopnea
  • hemoptysis
  • palpitations

exam

  • opening snap with diastolic rumble heard at apex
  • loud S1 and P2
  • JVD
  • edema, hepatic congestion

treatment

  • heart rate control
  • diuretics if  pulmonary congestion
  • warfarin if atrial fibrillation
  • surgery: ballon valvotomy or valvuloplasty

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15

Patent Ductus Arteriosus

 

Review specific heart disease that present as a murmur in children, including: PDA

  • very common
  • increased incidence in premature babies
  • tx: surgical ligation, device, coil
  • no SBE prophylaxis

Murmur

  • Continuous murmur @ LUSB to left infraclavicular region
  • Wide pulse pressure, bounding pulses
  • May have increased LV impulse
  • Largest may have diastolic thrill @ LUSB
  • May have LVH on EKG
  • May have cardiomegaly and pulmonary plethora on x-ray

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16

Pulmonary Stenosis

 

Review specific heart disease that present as a murmur in children, including: Pulmonary Stenosis

  • systolic gradient across valve > 25 mmHG
  • mildly thickened valve in neonate can resolve with time

Murmur

  • Systolic Ejection Murmur @ LUSB with radiation to back
  • May have systolic thrill
  • May have increased RV impulse
  • Usually with ejection click
  • May have RVH on EKG
  • May have prominent MPA on X-ray

17

Innocent Murmurs: Stills Murmur

 

Describe the evaluation of heart murmurs in children, being able to differentiate between pathologic and innocent murmurs: Still’s murmur

 

Timing: Systolic Ejection

Intensity: 1-3/6

Location: Several cm lateral to LLSB

Pitch: Low

Character: Vibratory, Musical

Helpful Maneuvers:  Standing vs. Supine