Term 5 - PathoPhysio > VALVULAR HEART DISEASES 1 > Flashcards

Flashcards in VALVULAR HEART DISEASES 1 Deck (20):

  • First Heart Sound (S1): 
  • Signals the beginning of ventricular systole - Generated by mitral and tricuspid valve closure
  • What does a Loud S1 signify? 

  1. Mitral stenosis
  2. Short PR interval
  3. Tachycardia
  4. Hyperdynamic states


What does a SOFT S1 signify? 

  1. Mitral regurgitation
  2. Long PR interval
  3. Poor systolic function
  4. Aortic/pulmonary regurgitation


  • Second Heart Sound (S2): Generated by the closure of the aortic (A2) and pulmonic (P2) valves – A2P2
  • Loud S2?

  1. Systemic hypertension
  2. Pulm hypertension
  3. Atrial septal defect


Soft S2:

  1. Aortic stenosis
  2. Pulmonic stenosis
  3. Aortic regurgitation
  4. Pulmonary regurgitation


Splitting of S2 (A2 - P2):

  • Normal split: A2P2 heard as two sounds during deep inspiration and single during expiration
  • Wide splitting of S2 (with normal respiratory variation) occurs when P2 is delayed (e.g., Right Bundle Branch block)
  • Fixed splitting of S2 occurs when respiration induced changes in filling are similar in both ventricles: e.g.,characteristic in atrial septal defect (ASD)


  • Paradoxical splitting of S2 (P2 - A2)
  • Occurs in:


  • Left Bundle Branch Block because of a delay in left ventricular depolarization; -Severe Aortic stenosis because of a delay in closure of aortic valve.
  • In paradoxical splitting, the interval from P2 to A2 shortens during inspiration (Note: Normally the interval from A2 to P2 lengthens during inspiration)


Ventricular gallop (S3):

  • Occurs in early diastole; Corresponds to the end of the rapid filling of the ventricle.
  • Caused by interplay between ventricular filling and existing ventricular (end-systolic) volume.
  • Normal S3 is a low-frequency sound, best heard at the apex (in case of LV_S3) or left lower sternal border (in case of RV_S3).
  • Pathologic S3 is associated with abnormally high ventricular filling, low cardiac output, or a dilated, poorly contractile ventricle.
  • Hallmark sign of ventricular (heart) failure.


Atrial gallop (S4):

  • A dull, low-frequency sound that precedes S1
  • Best heard over apex with the bell of the stethoscope in the left lateral position
  • The S4 is attributed to forceful atrial contraction to fill a noncompliant or stiff ventricle (e.g., coronary artery disease).
  • The S4 disappears in atrial fibrillation.


  • Classification:
  • Systolic murmurs– 
  • Diastolic murmurs– 

  • Systolic murmurs– while the ventricle is contracting; between S1 and S2 
  • Diastolic murmurs– while ventricle is filling; between S2 and S1


Pansystolic (holosystolic) Murmur

  • Mitral regurgitation - best heard at Apex
  • VSD - best heard at Lower left sternal border
  • Tricuspid regurgitation - best heard at Lower left sternal border


Early systolic (Midsystolic):

  • Aortic stenosis - best heard at Second IS
  • Hypertrophic obstructive cardiomyopathy - best heard at Apex, LLSB

LLSB=Lower left sternal border


Late systolic murmur

Mitral valve prolapse best heard at Apex, Lower left sternal border


Early diastolic: (high pitched, decrescendo) murmur

  • Aortic Regurgitation - Left sternal border, third intercostal space


Middiastolic: (low pitched) Murmur

  • Mitral stenosis - Apex, with the bell
  • Tricuspid stenosis - Left sternal border


Continuous murmur: (systolicdiastolic)

Patent ductus arteriosus (PDA) - Left first and 2 intercostal spaces, Left sternal border

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Pathophysiology of AS:

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Aortic stenosis: Hemodynamic changes

  • Narrowing around the aortic valve
  • Aortic valve acts as major resistance for flow (afterload) during ejection
  • Left ventricular pressure rises to very high levels during systole
  • Left ventricular hypertrophy
  • Systolic murmur appears

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Clinical Manifestations of AS and basis:

  • The three characteristic features of AS are: Chest pain, Syncope & CHF
  1. Chest pain (angina pectoris):
    • Mechanisms –
    • coronary artery disease;
    • increased oxygen demands because of ventricular hypertrophy;
    • decreased oxygen supply as a result of excessive compression of the vessels;
    • coronary artery obstruction from calcium emboli arising from a calcified stenotic valve
  2. Syncope:
    • Syncope is due to decreased cerebral perfusion Cause for syncope in AS –
    • the fixed obstruction to out flow;
    • transient atrial arrhythmias with loss of effective atrial contribution to ventricular filling;
    • arrhythmias arising from ventricular tissues
  3. Congestive heart failure (CHF)
    • LVH → diastolic dysfunction of LV → progressive increase in left ventricular end-diastolic pressure → elevated pulmonary venous pressure → pulmonary edema → RVF


Physical examination in AS:

  • Palpation of the carotid pulse reveals a pulsus parvus et tardus - both decreased (parvus) and late (tardus) relative to the apical impulse
  • Auscultation:
    • Midsystolic or earlysystolic murmur is heard, loudest at the base of the heart, and often with radiation to the sternal notch and the neck 
    • High-pitched aortic ejection click can be heard just after the first heart sound (S1) 
    • Fourth heart sound (S4) is often present