Heart sounds and murmurs

Question 1

What do the normal heart sounds represent?

Answer 1

• S1 “lub”: closure of mitral & tricuspid valves
• S2 “dub”: closure of aortic & pulmonary valves

Question 2

Explain a third heart sound (S3)

Answer 2

• Blood entering stiff/dilated ventricles during early diastole
• S3 due to decelerated blood flow at ventricular elastic limit
• Low-frequency brief vibration

Question 3

Give two causes of a third heart sound

Answer 3

Normal in children and young adults (<30)

• Heart failure
• MI
• Cardiomyopathy
• HTN

Question 4

Explain a fourth heart sound

Answer 4

• Atrial contraction into non-compliant/hypertrophied ventricle
• Low pitched ‘Gallop’ at end diastole

Question 5

Give two causes for a fourth heart sound

Answer 5

Always abnormal

• Heart failure
• MI
• Cardiomyopathy
• HTN

Question 6

What are the important features when describing a murmur?

Answer 6

• Systolic or diastolic
• Pan/Ejection/Mid
• Where it is heard best
• Where it radiates to

Question 7

How does ventilation affect auscultation of murmurs?

Answer 7

• Inspiration: vice-versa for expiration
  
  • Increases venous return to right side of heart
  • Decreases pulmonary return to left side of heart
• Therefore:
  
  • Right-sided murmurs (T/P) louder on inspiration​
  • Left-sided murmurs (M/A) louder on expiration

Question 8

Outline the grading of murmurs

Answer 8

Question 9

Describe the auscultation findings of mitral stenosis

Answer 9

• ‘Rumbling’ mid-diastolic murmur
  
  • Bell at apex; pt lying on left side
• Loud S1
• ‘Opening snap’

Question 10

Name two signs (other than on auscultation) of mitral stenosis

Answer 10

• Malar flush
• Low volume pulse
• AF
• CXR
  
  • Enlarged left atrium
  • Pulmonary oedema

Question 11

Name one cause of mitral stenosis

Answer 11

• Rheumatic heart disease
• Old age; calcification

Question 12

Describe the auscultation findings of mitral regurgitation

Answer 12

• Pansystolic “blowing” mumur
• Radiating to axilla

Question 13

Name two signs (besides auscultation) of mitral regurgitation

Answer 13

• Malar flush
• Displaced apex beat
• Palpable thrill

Question 14

Give two causes of mitral regurgitation

Answer 14

• Prolapsing mitral valve
• Rheumatic mitral regurgitation
• Papillary muscle rupture post-MI
• Cardiomyopathy
• Connective tissue disorders:
  
  • Marfan’s syndrome
  • Ehlers Danlos
  • Osteogenesis imperfecta

Question 15

Describe the auscultation findings of aortic stenosis

Answer 15

• Ejection systolic murmur
• Radiating to carotids

Question 16

Give two signs (besides auscultation) of aortic stenosis

Answer 16

• Slow rising pulse
• Narrow pulse pressure
• Forceful apex beat

Question 17

Name two causes of aortic stenosis

Answer 17

• Bicuspid aortic valve
• Age-related calcification
• Rheumatic fever

Question 18

Provide three presenting features of aortic stenosis

Answer 18

• Asymptomatic
• Exercise-induced:
  
  • Syncope
  • Angina
  • Dyspnoea

Question 19

Describe the auscultation findings of aortic regurgitation

Answer 19

• High-pitched early diastolic murmur
• Best heard at left sternal edge in 4^th intercostal space
• Patient lent forward

Question 20

Give two signs (besides auscultation) of aortic regurgitation

Answer 20

• Collapsing pulse: wide pulse pressure
• Quincke’s sign: capillary pulsation in nail beds
• De Musset’s sign: head nodding with heartbeat
• Pistol shot femorals

Question 21

Give two causes of aortic regurgitation

Answer 21

• Rheumatic fever
• Bicuspid valve
• Infective endocarditis
• Marfan’s syndrome
• Tertiary syphilis

Question 22

Outline the treatment of aortic stenosis

Answer 22

• Diuretics for symptomatic relief
• SAVR or TAVI
• Balloon valvuloplasty pre-TAVI