Murmurs Flashcards
(93 cards)
1
Q
Ventricular systole
A
The interval between the 1st (S1) and 2nd (S2) heart sounds
2
Q
Ventricular diastole
A
The interval between the 2nd (S2) and 1st (S1) heart sounds
3
Q
What is the first heart sound (S1) associated with?
A
Mitral and tricuspid valve closure
4
Q
What is the 2nd heart sound (S2) associated with?
A
Aortic and pulmonic valve closure
5
Q
Sysolic clicks
A
Ejection sounds produced in mid to late systole
MC associated with MVP
6
Q
Opening snap
A
The opening of abnormal mitral or tricuspid valves in the presence of rheumatic valvular stenosis
7
Q
How can cardiac murmurs be described?
A
Intensity through grade Pitch Quality Timing Shape (crescendo, etc.) Location Radiation
8
Q
Grades of murmurs
A
I- the faintest murmur that can be heard (with difficulty)
II- faint but can be identified immediately
III- moderately loud; NO thrill
IV- loud and is associated with a palpable thrill
V- very loud but cannot be heard without the stethoscope
VI- Loudest and can be heard without a stethoscope
9
Q
How can the majority of heart murmurs be categorized?
A
Midsystolic and soft (grades I-II)
10
Q
Which murmurs always need to be worked up?
A
Loud, holosystolic or late systolic murmurs, diastolic murmurs or continuous murmurs
11
Q
Innocent murmurs
A
Grade 1-2 (mid) systolic ejection murmurs
NEVER
-Grade 4 or more
-Pansystolic
-Diastolic
-Continuous
-Other abnormal sounds - e.g. fixed splits S2
12
Q
Venous hums
A
High flow states- e.g. anemia
Goes away when lying down
13
Q
L-sided heart failure sx
A
PND Elevate PCWP Pulmonary congestion -Cough -Crackles -Wheezes -Blood-tinged sputum -Tachypnea Restlessness Confusion Orthopnea Exertional dyspnea Fatigue Cyanosis
14
Q
Rt-sided heart failure sx
A
Fatigue Increased peripheral venous pressure Ascites Hepatosplenomegaly May be secondary to chronic pulmonary problems JVD Anorexia and complaints of GI distress Weight gain Dependent edema Peripheral and facial cyanosis
15
Q
What is the #1 cause of R ventricular failure?
A
L ventricular failure
16
Q
Main systolic murmurs
A
Mitral regurg
Aortic stenosis
17
Q
Other systolic murmurs
A
Tricuspid regurg Pulmonic stenosis VSD HCM ASD
18
Q
Main diastolic murmurs
A
Aortic regurg
Mitral stenosis
19
Q
Other diastolic murmurs
A
Pulmonic regurg
Tricuspid stenosis
20
Q
Aortic stenosis
A
Narrowing of the aortic valve
Etiology
-Congenital (uni- or bicuspid valve)
-Calcification/degeneration
21
Q
Risk factors for aortic stenosis
A
HTN
Hypercholesterolemia
Smoking
22
Q
S/sx of aortic stenosis
A
SAD- syncope, angina, dyspnea
Chest discomfort
Heart failure/death
Dyspnea and decreased exercise tolerance
-MC symptom
-Diastolic dysfunction with an increase in LV filling pressures with exercise
-Inability of the LV to increase the CO during exercise
23
Q
Characteristics of aortic stenosis
A
Crescendo-decrescendo harsh murmur
-Ejection murmur
-Late peaking = more severe
Radiates in forward direction to carotids
Possible decreased or absent 2nd heart sound
-Soft and single S2
Possible S4
24
Q
Diagnostics for aortic stenosis
A
Delayed carotid upstroke
CXR-usually nl
EKG- LVH, +/-Left atrial enlargement (LAE)
Echo- valve size and gradient
-Severe AS= valve area <1.0 cm squared, jet velocity over 4.0 m/sec, mean transvalvular gradient greater than or equal to 40 mmHg
25
Indication of LVH in EKG
Very tall R wave in V5 and V6
26
Staging of valvular disease
A is least, D is worst
| C is asymptomatic, D is symptomatic
27
Medications for aortic stenosis
Diuretics
| Beta-blockers
28
Surgery/procedures for aortic stnosis
Aortic valve replacement
-Tissue vs mechanical
Balloon valvuloplasty
Transcatheter aortic valve replacement (TAVR)
29
Complication of balloon valvuloplasty
Can cause calcium breakoff
30
Tissue valves
Last 10-15 yrs
Bovine or porcine
Porcine is gold standard
Anticoagulation not required
31
Mechanical valves
Last 1,000 years
Made of titanium or pyrolytic carbon
Warfarin anticoagulation REQUIRED
32
What is indicated for both types of valves?
Endocarditis prophylaxis
33
What is the gold standard for entrance of catheter for a TAVR?
Femoral artery
34
Ross procedure
Cut out pulmonic valve and put it into aortic position. Put cadaver or tissue valve in pulmonic position
Pros- their own tissue, shouldn't need to be replaced. Other valves lasts 30-40 yrs
35
Mitral regurg causes
```
MVP
Ischemia/infarction
-MI with ruptured chordae tendinae
-Ischemia is responsible for 3-25% of MR, severity is directly proportional tot he amount of LV hypokinesis
Acute rheumatic heart disease
Calcification
```
36
Mitral valve prolapse
Floppy, degenerative, or myxomatous
| Seen in up to 10% of healthy young women
37
S/sx of MVP
Asymptomatic
Nonspecific CP, dyspnea, fatigue, or palpitations
Possible skeletal deformities (pectus excavatum, scoliosis)
Mid-systolic click +/- systolic murmur
38
Diagnostics for MVP
Echo
39
Medications for MVP
Beta blockers
40
Surgery for MVP
Mitral valve repair > mitral valve replacement
41
S/sx of mitral regurg
Acute-pulmonary edema signs
Chronic- exertional dyspnea, fatigue over time
Palpitations- possible a-fib
42
Characteristics of mitral regurg
Pansystolic murmur (high-pitched "blowing")
-Radiates to the axilla
Possible S3
43
Diagnostics for mitral regurg
```
Lab
-BNP: early identifier of LV dysfunction
Echo
-Regurgitant volume
-Ejection fraction
-LA size
-LV size, PA pressure, RV function
```
44
Medical mitral regurg tx
Diuretics and beta blockers
Vasodilators like ACE-I often helpful
Warfarin for a-fib
45
Surgery for mitral regurg
Acute case-emergent surgery
-Stabilize first with vasodilators and/or intra-aortic balloon pumps
Chronic cause- elective surgery
-Data proves early surgery indicated even in asymptomatic pts (depends on LV function)
-Best results are achieved in pts with an EF >60% and an end-systolic size <4.5 cm
46
Indications for intra-aortic balloon pump (IABP)
Myocardial ischemia/infarction
| Mitral regurg
47
Contraindications for intra-aortic balloon pump (IABP)
Aortic insufficiency
Aortic dissection
Severe aortic atherosclerosis
48
Primary care f/u for mitral regurg
Pts with ONLY mild MR and no evidence of LV enlargement, LV dysfunction, or pulmonary htn should undergo echocardiography every 3-5 yrs
Refer all other pts to cardiology for more frequent f/u
49
Etiology of aortic regurg
```
Rheumatic-rare
Nonrheumatic
-HTN
-Bicuspid valve
-Infective endocarditis
-Marfan syndrome
-Aortic dissection
-Inflammatory diseases
```
50
S/sx of aortic regurg
```
Asymptomatic
Exertion dyspnea
Fatigue
Atypical CP
Eventual LV failure
```
51
Pathophysiology of aortic regurg
Increased SV
-Bounding pulses with rapid rise and fall
--Water-hammer pulse or Corrigan pulse
--Quincke pulses (nailbed capillar pulsations)
--Musset sign (head bob with each pulse)
--Hill sign (40 mmHg higher BP in the LE compared to UE)
Wide pulse pressure
-Elevated systolic and low diastolic pressure
52
Corrigan pulse
Characterized by a rapidly swelling and falling arterial pulse. This finding is generally best appreciated by palpation of the radial or brachial arteries (exaggerated
by raising the arm) or the carotid pulses
53
deMusset's sign
A head bob occurring with each heart beat
54
Traube's sign
A pistol shot pulse (systolic and diastolic sounds) heard over the femoral arteries
55
Duroziez's sign
A systolic and diastolic bruit heard when the femoral artery is partially compressed
56
Quincke's pulse
Capillary pulsations in the fingertips or lips
57
Mueller's sign
Systolic pulsations in the uvula
58
Becker's sign
Visible pulsations of the retinal arteries and pupils
59
Hill's sign
Popliteal cuff systolic pressure exceeding brachial pressure by more than 20 mmHg with pt in the recumbent position
60
Mayne's sign
More than a 15 mmHg decrease in diastolic BP with arm elevation from the value obtained with the arm in the standard position
61
Rosenbach's sign
Systolic pulsations of the liver
62
Gerhard's sign
Systolic pulsations of the spleen
63
Characteristics of aortic regurg
High-pitched and decrescendo diastolic murmur
Radiates to the apex
Better heard when sitting and leaning forward
+/- Austin Flint murmur
-Due to partial closing of the anterior leaflet of the mitral valve
64
Diagnostics of aortic regurg
EKG- LVH
| Echo-regurgitant volume
65
Tx of aortic regurg
```
Medical- diuretics, BBs, nifedipine, ACE-I
-ARBs with Marfan disease
Surgery- aortic valve replacement
-Aortic root replacement
-Ross procedure
```
66
Indications for valve replacement in pts with severe aortic regurg
1. The onset of sx
2. LV dysfunction (EF <50%) and
3. severe LV dilatation (end-systolic size >5.5 cm)
67
Mitral stenosis
The MV leaflets thicken, the commissures fuse, calcium deposits on the valve, and the chordae tendinae thicken and shorten
68
Etiology of mitral stenosis
Almost always the result of rheumatic fever
-2/3 are female pts
Less common causes include congenital MS, SLE, RA, atrial myxoma, and bacterial endocarditis.
69
S/sx of severe mitral stenosis
```
DOE- most common complaint
-D/t pulmonary venous hypertension
Palpitations
Atrial fib
Cough
Orthopnea
CP
Thromboembolism
```
70
PE of mitral stenosis
```
Pulmonary edema (rales)
+/- irregularly irregular heart rate
Left and possible right heart failure sx
Cutaneous vasoconstriction results in pinkish-purple patches on the cheeks
Mallor rash- lupus is in differential
```
71
Murmur characteristics of mitral stenosis
Diastolic murmur (low-pitched rumbling)
-Best heard in left lateral decubitus position
Opening snap
-Extra diastolic sound that follows A2
Pulmonary hypertension
-If present, +/- RV lift; an increased pulmonic S2 sound; and a high-pitched, decrescendo, diastolic murmur of pulmonary insufficiency
72
CXR findings for mitral stenosis
```
Left atrial enlargement
-Straightening of the left heart border
-Retrocardiac double density
-Elevation of left bronchus
+/- enlarged pulmonary artery
+/- calcification in mitral valve area
```
73
EKG findings in mitral stenosis
```
Atrial fib is common
Left atrial enlargement
-P mitrale
-Broader P wave in lead II that is notched
+/- RAD
+/- RVH
```
74
What is the most sensitive and specific noninvasive test for mitral stenosis?
Echocardiography
75
Echo findings for mitral stenosis- valve area
Mild: >1.5 cm squared
Moderate: 1.0-1.5 cm squared
Severe: <1.0 cm squared
76
Medical tx of mitral stenosis
Diuretics and beta blockers
-Diuretic (usually loop) for pulmonary vascular congestion
-Beta blockers for heart rate control
-CCB if BB contraindicated, digoxin for rate control of a fib
Warfarin for a fib or left atrial thrombus
-INR goal: 2.5
77
Non-surgical tx of mitral stenosis
Percutaneous mitral balloon commissurotomy (PMBC)
78
Surgical tx of mitral stenosis
Open mitral commissurotomy and valve repair
Mitral valve replacement +/- MAZE procedure
-Tissue vs. mechanical
-+/- Maze procedure
-+/- left atrial appendage amputation
79
Etiology of tricuspid stenosis
Rheumatic
Carcinoid syndrome
Fen-Phen
80
S/sx of tricuspid stenosis
Right heart failure
Giant a wave seen in the JVP
Diastolic rumble murmur
-Increases with inspiration
81
Diagnostics of tricuspid stenosis
EKG- RA enlargement
CXR- cardiomegaly, dilated SVC
Echo- stenosis
82
When does tricuspid regurgitation occur?
```
Occurs whenever there is RV dilation from any cause
Pulmonary valvular stenosis
Pulmonary HTN
Cardiomyopathy
RCA myocardial infarction
Heart failure
Endocarditis
```
83
S/sx of tricuspid regurgitation
Right-sided heart failure
JVP- x wave becomes obliterated
Systolic murmur that increases with inspiration
84
Diagnostics of tricuspid regurgitation
EKG- RA enlargement
| Echocardiogram
85
Tx of tricuspid regurgitation
```
Diuretics
-Aldosterone antagonists if ascites
Tricuspid annuloplasty
Valve replacement
-Bioprosthetic valve (no anticoagulation)
```
86
S/sx of pulmonary valve stenosis
DOE
CP
Eventual RV failure
87
PE of pulmonary valve stenosis
Palpable parasternal lift d/t RV hypertrophy
Loud, harsh systolic murmur +/- thrill (2nd ICS)
-Increases with inspiration
Ejection click that precedes the murmur
-Decreases with inspiration
-P2 delayed and soft or absent
88
Diagnostics of pulmonary valve stenosis
EKG: +/- RAD, RVH
Echo: diagnostic tool of choice
89
Tx of pulmonary valve stenosis
Symptomatic pts with peak gradient >60 mm
Percutaneous balloon valvuloplasty
Surgical commissurotomy or pulmonary valve replacement
90
Etiology of pulmonary valve regurgitation
Most cases are d/t pulmonary hypertension
Abnormal valve
Plaque from carcinoid disease
Post-surgical Tetralogy of Fallot repair
91
S/sx of pulmonary valve regurg
```
Most are asymptomatic
Hyperdynamic RV
-RV heave, lift
2nd heart sound may be widely split
Diastolic murmur increases with inspiration
```
92
Diagnostic of pulmonary valve regurg
Echo
93
Tx of pulmonary valve regurg
Diuretics
Pulmonary valve replacement
-If RV enlargement or dysfunction is present
