Heart Sounds Flashcards
(20 cards)
Aortic stenosis/sclerosis
Hypertrophic obstructive cardiomyopathy/IHSS
one of the most common murmurs
important reversible cause of HF, syncope and death
in young-could be bicuspid aortic valve
sustained apical impulse?
thrill over aortic valve?
pulses weak/late? (delay from carotid to radial, brachial to radial) parvus et tardus
timing - systolic, diamond (might be holo)
location - aortic, beauty sash
radiate - to clavicle
pitch - harsh
intensity - does not correlate with severity
maneuvers - inc afterload, dec. murmur (handgrip, arterial occlusion
may hear early systolic ejection sound (opening of aortic valve)
high LR of severe AS - late peaking, absent S2, brachioradial or apical carotid delay
Mitral regurg
systolic murmur
inspect - apical impulse displaced laterally/inferiorly, LV heave
palpation - pulse rapid, bounding
S3 may be heard and felt, rapid filling in early diastole, may be mistaked for obscured S2
shape - holosystolic, may be mid or late systole
location - loudest at apex
pitch - blowing, high, musical
radiation - axilla
intensity - correlates with severity (unless EF low)
transient arterial occlusion accentuates
Tricuspid regurg
right ventricle regurg taking a breath in increases murmur seen in severe cardiac/pulm/hepatic dx pulse pressure wide bounding jugular vein bobbing of earlobe side to side head bob - proptosis pulsatile liver? high pres - holosystolic (like MR) or mid to late systolic low pressure - like endocarditis, may be inaudible maneuvers - inc with inspiration (Rivero-Carvallo), more apparent with stading passive leg raise increases abdominojugular reflex increases neck veins helpful
Aortic insufficiency/Regurg
often missed - subtle
early diastolic murmur
pathologic, must be assessed
arterial pulses are bounding due to LARGE PULSE PRESSURES
shape - decrescendo
location - LUSB, LLSB
radiation - varies, top of head, elbow
if rad to RSB, think root dilation or endocarditis
high pitch, soft
maneuvers - high BP (before meds), held exp, leaning forward, transient arterial occlusion, exercise
Mitral stenosis
rare but catastrophic use BELL 3rd world - rheumatic fever mid-diastolic (after opening snap) mid decresc, late cresc heard at APEX, coarse, rumbling, very soft LOUD S1 RV lift, felt/seen Opening snap, from LSB to apex later than S2 split, higher pitch/earlier than S3 Maneuvers - LL decub, exercise, opening snap separates from S2 with STANDING
systolic murmur causes
stenotic ventricular outflow or regurgitant ventricular inflow
aortic/pulmonic stenosis
mitral/tricuspid regurg
diastolic murmur causes
from regurgitant ventricular outflow or
stenotic ventricular inflow
aortic/pulmonic regurg,
mitral/tricuspid stenosis
mitral valve prolapse
variant of mitral regurg
systolic murmur starts after pause after S1
systolic click may be heard prior to murmur
redundancy of mitral valve apparatus (leaflets or chordae tendineae)
louder with less blood (standing)
peripheral signs of chronic AI
large pulse pressure (>50mmHg)
water hammer pulse-collapsing/bounding/twice beating, best felt with thumb
Corrigan’s pulse - visible, bounding carotid pulsation
Hill’s sign - patient supine, LE pulse > 20 of UE, correlates with severity
Respiration (maneuver) does what
RIvero-Carvallo’s sign
inc venous return to rt. heart
inc rt. heart sounds
not as great in rt. sided HF
squatting (maneuver) does what
inc venous return, stroke volume, systemic resistance examiner remains seated may need to repeat will INCREASE AI no change with most systolic murmurs will dec. HOCM and MVP
Standing (maneuver) does what
dec venous return, most murmurs softer
HCM and MVP louder/longer, clicker earlier d/t smaller vent. volume
very sens/spec for HCM
Valsalve (maneuver) does what
STRAIN - inc intrathoracic pressure, dec venous return, most murmurs softer, except HCM and MVP
RELEASE phase- use to distinguish rt from lt sided murmurs by # of beats
RT 1-4 cycles, LT 4-12 cycles
help distinguish normal from paradoxical S2
NORMAL - strain phase, split narrows, widens with release
PARADOXICAL - widens with strain, narrows with release
Isometric exercise (maneuver) does what
60-90 sec handgrip, inc HR, BP and CO, aortic pressure Inc vent pressure, inc. MR, MVP and VSD Inc AI Dec HOCM and AS Gallops and MS rumbles louder no effect on S3 or knock
Transient arterial occlusion
bp cull on b/l arm, inflate to 20-40 mmHg
INCREASE left sided regurg murmur (good spec/sens) AI, MR, VSD
Increased afterload - DECREASE AS, HOCM
no effect on TR
Organic/pathologic murmur
all diastolic murmurs
all pansystolic and late systolic murmurs
all continuous murmurs
all grade 4 and above
the company it keeps - clicks, gallops, heaves etc
Functional/innocent murmurs
30-40% of adults have soft ejection murmurs grade 1-2, never 4-6 LSB Low to medium pitch radiates poorly inc with maneuvers that inc flow no red flags, keep no bad company
3 types of holosystolic murmurs
TR, MR or VSD look at neck veins for TR Radiation/gallops for MR Try carvallo's or abdominojugular reflux for TR transient arterial occlusion for MR/VSD Valsalva for HOCM
systolic murmur
ejection type - AS, HOCM, MR/MVP, TR, VSD all
find point of maximal loudness
Maneuvers - respiration, valsalva, posture, TAO
diastolic murmur
AI ,MS the main causes
Pulmonary insufficiency from pulm htn and Austin Flint (MS from AI)
Early favors AI, mid-late MS
Peripheral manifestations of AI?
Opening snap of MS? May need to exercise, turn to left lat decubitus
TAO to bring out AI
