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Flashcards in ThirteenA Deck (19)
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Mitral, Tricuspid, Aortic, Pulmonic


What does S1 signify? What can change the intensity?

Onset of systole

Intensity is usually always the same, but is altered by:

Distance between open AV leaflets at the onset of
Larger distance = Louder S1

Mobility of valve leaflets

Rate of rise of ventricular pressure


What does S2 signify? Describe the things that may alter it and why?

S2 signifies the end of ventricular systole

Aortic component (A2) precedes pulmonic component (P2)

A2 and P2 components can vary in timing based upon
respiratory variations

Inspiration: Decrease in intrathoracic pressure leads to increased venous return to the right heart
Pulmonic valve stays open slightly longer
Increase in pulmonary vascular capacitance
Blood trapped in pulmonary vascular bed
Less blood flow returns to left heart
Aortic valve closes slightly earlier

Expiration brings A2 and P2 back together


Describe widely split S2.

S2 split at both expiration and inspiration

Delayed closure of the

pulmonic valve

Right bundle branch block

Respiratory variation still present


Describe Fixed Split S2. Cause?

Widely split S2 without

respiratory variation

Classic cause is an atrial septal defect

Chronic shunting of blood from the left heart to right

Delayed pulmonic valve closure


What is a paradoxically split S2?

Describes the situation where the aortic valve closes after the pulmonic valve

S2 sounds normal with inspiration, but paradoxically
splits with expiration

Left bundle branch block, right ventricular pacing


How are murmurs graded? How are the systolic murmurs classified?

Graded from 1 to 6, based on the intensity of the sound

Murmurs can be classified as


Systolic ejection

Late systolic


What are holocystic murmurs? What are 3 examples? Describe them. How are they recognized clinically?

Onset occurs as soon as systole begins

Mitral regurgitation

Incompetent mitral valve that is unable to prevent backflow of blood into the left atrium
Loudest at cardiac apex

Tricuspid regurgitation
Louder with inspiration
Loudest at lower sternal border

Ventricular septal defect
Typically a harsher/louder murmur, associated with a palpable thrill


When do systolic murmurs begin and end? What are they like? Examples?

Onset begins after IVCT

Stenosis of either semilunar valve (aortic stenosis or
pulmonic stenosis)
Flow across the diseased heart valve begins only after the
systolic pressure exceeds the pressure in the great vessel

Typically “diamond-shaped” or crescendo-decrescendo

Murmur ends at S2


Describe aortic stenosis? Where is it best heard? What happens when the stenosis worsens? What happens to carotid pulse?

Systolic ejection murmur, heard best at the right upper sternal border

May radiate to carotid arteries

As the valve becomes more

stenotic, the murmur peaks

later in systole

Obliteration of S2

Carotid pulse demonstrates diminished and delayed
upstroke (pulsus parvus et tardus)


Flow murmurs

Younger patients can often have innocent flow murmurs

Because of robust cardiac output, there can be increased blood flow across the semilunar valves during systole

These murmurs are typically very soft (grade 1 or 2)

Early-mid peaking

Not pathologic


What are late systolic murmurs? Give two examples.

Murmur begins in mid to late


Two classic conditions which

cause this type of murmur

Mitral valve prolapse (MVP)

Hypertrophic obstructive

cardiomyopathy (HOCM)


describe mitral valve prolapse. What is the murmur like?

Myxomatous degeneration of

the mitral valve leaflets

Creates redundant (“floppy”)

mitral tissue

Mitral valve closes normally in

early systole

Redundant mitral tissue

prolapses into the left atrium in

mid systole

Prolapse of excess mitral tissue

creates a mid-systolic click

The mitral valve leaflets are

redundant and too long for the

left ventricle

Decreasing left ventricular

volume exacerbates this


Strain phase of the Valsalva

maneuver and standing from a

squatting position reduces left

ventricular preload


What is HOCM? What is the murmur like?

Genetic condition characterized

by severe asymmetric septal


During systole, dynamic

obstruction of left ventricular


Late-peaking systolic ejection

murmur in the aortic region


Maneuvers that reduce left

ventricular volume increases

the left ventricular outflow


Louder murmur

Increasing afterload (handgrip

maneuver) reduces murmur



What are diastolic murmurs like?

More difficult to appreciate than

systolic murmurs

By definition, diastolic murmurs

begin after S2

Unlike systolic murmurs, an

audible diastolic murmur is

never normal

Diastolic murmurs graded from

1 to 4


Describe aortic regurgitation. What is the murmur like? Other physical findings?

Decrescendo diastolic murmur

Incompetent aortic valve allows blood to backflow into the left ventricle

Increased left ventricular blood volume is ejected across the aortic valve in systole
Systolic ejection murmur

Loudest at the right upper sternal border, with the patient sitting forward and after expiration

Reduced diastolic blood pressure

Widened aortic pulse pressure

Austin-Flint murmur

Eponymous physical findings all over the place

Most of the physical findings

in chronic severe aortic

regurgitation are secondary

to the widened aortic pulse



What is mitral stenosis? Most common cause? What is the murmur like?

Obstruction to left ventricular inflow

Most common cause is rheumatic heart disease

Murmur is a low-pitched diastolic murmur at the apex

Very difficult to hear because of the relatively low pressure gradients

at which it occurs

Mid diastolic murmur preceded

by an opening snap

Opening snap occurs earlier

in diastole as mitral stenosis

becomes more severe


When is S3 heard? What causes it?

Large pressure gradient between the left atrium and left

ventricle in early diastole

Mitral valve opens and “passive” filling occurs

Rapid gush of blood across the mitral valve

S3 can be normal and also pathologic

In young, healthy patients, S3 can be normal and is the result of robust systolic heart function

More frequently, S3 is heard in pathologic conditions where left atrial pressure is elevated (decompensated congestive heart failure)


What causes an S4 murmur? What is it like? When can it never occur?

Atrial contraction occurs in late diastole

Heard in patients with longstanding systemic hypertension

Pathologic left ventricular hypertrophy

Non-compliant left ventricle

Left ventricular pressure increases in response to systemic


Atrial contraction occurs at higher left atrial pressure

Forceful atrial contraction against a non-complaint left ventricle

Organized atrial contraction is required to have an S4

Patients in atrial fibrillation (no organized atrial contraction)

cannot have an S4