Heart murmurs and sounds

Question 1

What is S1 caused by and what does it indicate?

Answer 1

Closure of mitral and tricuspid valves

Marks the start of ventricular systole

Question 2

What is S2 caused by and what does it indicate?

Answer 2

Closure of aortic and pulmonary valves

Marks end of ventricular systole and the start of diastole

Question 3

Why is S2 not always heard as one discrete sound and sometimes split?

Answer 3

Pulmonary valve may close just after aortic valve

Closure of pulmonary valve just after the aortic valve is prolonged during inspiration, or in defects which cause more blood to be pumped out of the right ventricle

Question 4

What is a thrill?

Answer 4

Palpable vibration caused by turbulent blood flow through a heart valve

Question 5

Murmur associated with aortic stenosis and where is it loudest

Answer 5

Ejection systolic murmur
‘Crescendo-decrescendo’
Radiates to carotid arteries

Heard loudest over aortic valve

Question 6

Causes of aortic stenosis

Answer 6

Calcification of aortic valves(most common)

Congenital abnormality of aortic valve(bicuspid aortic valve)

Rheumatic heart disease(rare)

Question 7

Clinical features of aortic stenosis not linked to murmur

Answer 7

Slow rising pulse with narrow pulse pressure

Non-displaced, heaving apex beat(indicates LVH)

Reduced or absent S2

Reverse splitting of S2

Question 8

Murmur associated with mitral regurg

Answer 8

Pansystolic murmur heard loudest over mitral area and radiates to the axilla

Question 9

Causes of mitral regurg

Answer 9

Infective endocarditis 
Acute MI with rupture of papillary muscles 
Rheumatic heart disease 
Congenital defects of mitral valve 
Cardiomyopathy

Question 10

Clinical features of mitral regurg

Answer 10

Heard loudest using the bell of the stethoscope
Loudest on expiration in the left lateral decubitus position
Displaced, hyperdynamic apex beat

Question 11

Murmur associated with aortic regurgitation

Answer 11

Decrescendo early diastolic murmur heard loudest at left sternal edge

Question 12

Causes of aortic regurg linked to valve pathology

Answer 12

Congenital bicuspid aortic valve
Rheumatic heart disease
Infective endocarditis

Question 13

Causes of aortic regurg linked to aortic root dilatation

Answer 13

Aortic dissection
Connective tissue diseases(e.g. marfan’s)
Aortitis

Question 14

Clinical features associated with aortic regurg

Answer 14

Austin flint murmur
Collapsing pulse
Displaced, hyperdynamic apex beat

Question 15

What is an Austin Flint murmur

Answer 15

Low pitched rumbling mid-diastolic murmur at apex

Question 16

What is an austin flint murmur caused by

Answer 16

Caused by regurgitated blood through the aortic valve mixing with blood from left atrium during atrial contraction

Sign of severe aortic regurg

Question 17

Murmur associated with mitral stenosis

Answer 17

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

Question 18

Causes of mitral stenosis

Answer 18

Rheumatic heart disease(most common)

Congenital

Question 19

Clinical features of mitral stenosis

Answer 19

Loudest in left lateral decubitus position on expiration
Low-volume pulse
Loud first heart sound with tapping apex beat
Malar flush

Question 20

Arrhythmia associated with mitral stenosis

Answer 20

Atrial fibrillation

Question 21

Murmur associated with mitral valve prolapse

Answer 21

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

Question 22

What is primary mitral valve prolapse caused by

Answer 22

Myxomatous degeneration of the mitral valve and is associated with connective tissue diseases

Question 23

Murmur associated with tricuspid regurg

Answer 23

Pansystolic murmur heard loudest over the tricuspid region

Question 24

Causes of tricuspid regurg

Answer 24

Right ventricular dilatation 
Rheumatic fever 
Infective endocarditis 
Carcinoid syndrome 
Congenital(ASD, Ebstein)

Question 25

What is the ebstein anomaly

Answer 25

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

Question 26

Clinical features of tricuspid regurg

Answer 26

Large 'v-waves' visible in the jugular veins(caused by right atrial filling against a closed tricuspid valve) Visible/palpable hepatic pulsations Signs of right-sided heart failure

Question 27

Signs of right-sided heart failure

Answer 27

Right ventricular heave Peripheral oedema Hepatomegaly Ascites

Question 28

Murmur associated with pulmonary stenosis

Answer 28

Ejection systolic murmur heard loudest over pulmonary area Radiates to left shoulder/left infraclavicular region

Question 29

Causes of pulmonary stenosis

Answer 29

Congenital Rheumatic fever Carcinoid syndrome

Question 30

Congenital causes of pulmonary stenosis

Answer 30

Turner's Noonan's Williams Tetralogy of fallot

Question 31

Clinical features of pulmonary stenosis

Answer 31

Prominent 'a waves' in jugular veins Widely split S2 Right ventricular dilatation may lead to signs of right-sided heart failure

Question 32

Clinical features of pulmonary regurg

Answer 32

Early decrescendo murmur heard loudest over the left sternal edge Loudest during inspiration Usually due to pulmonary hypertension(graham steell murmur)

Question 33

Causes of pulmonary regurgitation

Answer 33

Pulmonary hypertension Infective endocarditis Congenital valvular heart disease

Question 34

Murmur associated with tricuspid stenosis

Answer 34

Soft diastolic murmur loudest at 3rd-5th intercostal space at the left sternal edge

Question 35

Causes of tricuspid stenosis

Answer 35

``` Rheumatic fever(most common) Congenital disease Infective endocarditis ```

Question 36

Clinical features of tricuspid stenosis

Answer 36

Raised JVP with giant 'a waves' Peripheral oedema Ascites

Question 37

What are congenital VSDs often associated with

Answer 37

chromosomal disorders: Down's syndrome Edward's syndrome Patau syndrome cri-du-chat syndrome

Question 38

Acquired cause of VSD

Answer 38

Post MI

Question 39

Post-natal VSD presentation

Answer 39

failure to thrive ``` features of heart failure hepatomegaly tachypnoea tachycardia pallor ``` classically a pan-systolic murmur which is louder in smaller defects

Question 40

Mx of VSD

Answer 40

small VSDs which are asymptomatic often close spontaneously are simply require monitoring moderate to large VSDs usually result in a degree of heart failure in the first few months nutritional support medication for heart failure e.g. diuretics surgical closure of the defect

Question 41

Complications of VSD

Answer 41

``` Aortic regurgitation Infective endocarditis Eisenmger's complex Right heart failure Pulmonary hypertension ```

Question 42

What is coarctation of the aorta

Answer 42

Congenital narrowing of the descending aorta

Question 43

Features of aortic coarctation

Answer 43

infancy: heart failure adult: hypertension radio-femoral delay apical click from the aortic valve notching of the inferior border of the ribs (due to collateral vessels) is not seen in young children

Question 44

Murmur associated with aortic coarctation

Answer 44

Mid systolic murmur, maximal over back

Question 45

Aortic coarctation associations

Answer 45

Turner's syndrome bicuspid aortic valve berry aneurysms neurofibromatosis

Question 46

What might be seen on CXR in mitral stenosis

Answer 46

Left atrial enlargement

Question 47

What is a corrigan pulse/water-hammer pulse

Answer 47

Pulse that is forceful and then suddenly collapses usually found in patients with aortic regurg