Murmurs

Question 2

What mneumonic can be used to assess a murmur?

Answer 2

SCRIPT

• S – Site: where is the murmur loudest?
• C – Character: soft / blowing / crescendo (getting louder) / decrescendo (getting quieter) / crescendo-decrescendo (louder then quieter)
• R – Radiation: can you hear the murmur over the carotids (aortic stenosis) or left axilla (mitral regurgitation)?
• I – Intensity: what grade is the murmur?
• P – Pitch: is it high-pitched or low and rumbling? Pitch indicates velocity.
• T – Timing: is it systolic or diastolic?

Question 3

Grading system for murmurs

Answer 3

• Grade I: Difficult to hear
• Grade II: Quiet
• Grade III: Easy to hear
• Grade IV: Easy to hear with a palpable thrill
• Grade V: Audible with stethoscope barely touching the chest
• Grade VI: Audible with stethoscope off the chest

If in doubt → grade 2 or 3

Question 4

Example of describing a murmur in OSCE

Answer 4

“This patient has a harsh / soft / blowing, Grade …, systolic / diastolic murmur, heard loudest in the aortic / mitral / tricuspid / pulmonary area, that does not / radiates to the carotids / left axilla. It is high / low pitched and has a crescendo / decrescendo / crescendo-decrescendo shape. This is suggestive of a diagnosis of mitral stenosis / aortic stenosis.”

Question 5

Define mitral regurgitation

Answer 5

Backflow through the mitral valve during systole

(Flow from LV → LA)

Question 6

Causes of mitral regurgiation

Answer 6

• Idiopathic weakening of the valve with age
• Ischaemic heart disease
• Infective endocarditis
• Rheumatic heart disease
• Connective tissue disorders (Ehlers-Danlos syndrome or Marfan syndrome)

Question 7

Symptoms of mitral regurgitation

Answer 7

• Dyspnoea
• Fatigue
• Palpitations
• Symptoms of causative factor (e.g. fever)

Question 8

Signs of mitral regurgitation

Answer 8

• Pansystolic ‘high-pitched whistling’ murmur at the apex → radiating to the axilla
• Thrill (on mitral area) on palpation
• AF
• Signs of heart failure + pulmonary oedema
• Displaced hyperdynamic apex

MR = pansystolic murmur at the apex → radiating to the axilla

Question 9

Tests for mitral regurgitation

Answer 9

• ECG (AF, LVH)
• CXR (Big LA and LV, Mitral valve calcification, Pulmonary oedema)
• Transoesophageal echo = diagnostic

Question 10

Why use a transoesphogeal echocardiogram with mitral regurgitation

Answer 10

Assess LV function and MR severity and aetiology

Question 11

What does mitral regurgitation do to the ejection fraction?

Answer 11

Mitral regurgitation = reduces ejection fraction

MR = also causes backlog of blood waiting to be pumped through the left side of the heart → resulting in congestive cardiac failure.

Mitral regurgitation = second most common indication for valve replacement.

Question 12

Causes of mitral stenosis

Answer 12

• Rheumatic heart disease
• Infective endocarditis

Question 13

When do symptoms and signs of mitral stenosis appear?

Answer 13

When the mitral valve orifice area is less than 2cm squared
(usually 4-6cm squared)

Question 14

How does mitral stenosis present?

Answer 14

Pulmonary hypertension causes:
* Dyspnoea
* Haemoptysis
* Chronic bronchitis picture

Pressure from large left atrium on local structures causes:
* Hoarseness (recurrent laryngeal nerve)
* Dysphagia (oesophagus)
* Bronchial obstruction

Also:
* Fatigure
* Palpitations
* Chest pain
* Systemic emboli

Question 15

Signs of mitral stenosis

Answer 15

• Rumbling mid-diastolic murmur (‘low-pitched’)
• Malar flush on cheeks (due to ↓CO)
• AF (often due to enlarged LA)
• Tapping apex beat - which is palpable (prominent S1)
• Non-displaced apex beat

Murmur is low-pitched due to low blood flow velocity

There will be a loud S1 due to thick valves requiring a large systolic force to shut, then shutting suddenly. There is an opening snap after S2, which triggers the onset of the murmur.

Question 16

Tests for mitral stenosis

Answer 16

• ECG (AF, P-mitrale, RVH)
• CXR (LA enlargement, pulmonary oedema, mitral valave calcification)
• Transopesophageal echocardiogram = diagnostic

Question 17

Causes of aortic stenosis

Answer 17

• Age-related calcification (most common)
• Congenital (bicuspid aortic valve)
• Rheumatic heart disease

Question 18

Presentation of aortic stenosis

Answer 18

(Think about elderly person with chest pain, exertional dyspnoea or syncope)

Classic triad:
* Angina
* Syncope
* Heart failure

Other:
* Dyspnoea
* Dizziness
* Faints
* Systemic emboli (if IE)
* Sudden death

Question 19

Signs of aortic stenosis

Answer 19

• Slow rising pulse with narrow pulse pressure (feel for diminished and delayed carotid upstroke -* parvus et tardus*)
• Non-displaced apex beat (heaving)
• Ejection systolic murmur (radiates to carotids)

Question 20

Tests for aortic stenosis

Answer 20

• ECG (LVH with strain pattern, P-mitrale, LBBB or complete AV block (calcified ring))
• CXR (LVH, calcified aortic valve, post stenotic dilitation of ascending aortic)
• ** Echo (diagnostic)**
• Doppler echo (estimate gradient across valves)

Question 21

Differential diagnosis for aortic stenosis

Answer 21

• Hypertrophic cardiomyopathy
• Aortic sclerosis

Question 22

Causes of aortic regurgitation (acute and chronic)

Answer 22

Acute:
* Infective endocarditis
* Ascending aortic dissection
* Chest trauma

Chronic:
* Age-related weakness
* Bicuspid aortic valve
* Connective tissue disorders (Marfan’s, Ehlers-Danlos syndrome)
* Rheumatic fever

Question 23

Symptoms of aortic regurgitation

Answer 23

• Exertional dyspnoea
• Orthopnoea
• Palpitations
• Angina
• Syncope

Question 24

Signs of aortic regurgitation

Answer 24

• Collapsing pulse
• Wide pulse pressure
• Displaced hyperdynamic beat
• High-pitched early diastolic murmur

Question 25

Tests for aortic regurgitation

Answer 25

* ECG (LVH) * CXR (Cardiomegaly, dilated descending aorta, pulmonary oedema) * Echo (diagnostic)

Question 26

What is mitral stenosis?

Answer 26

Mitral stenosis = narrowed mitral valve Restricts blood flow from the LA → LV

Question 27

What valvular disease causes of malar flush?

Answer 27

**MITRAL STENOSIS** = causes **malar stenosis** Malar flush = refers to red discolouration of the skin over the upper cheeks and nose. It is due to the back pressure of blood into the pulmonary system, causing a **rise in CO2** + **vasodilation**.

Question 28

Why do patients with mitral stenosis (and regurgitation) also present with AF?

Answer 28

**Atrial fibrillation** = caused by the left atrium struggling to push blood through the stenotic valve **causing strain**, electrical disruption and resulting fibrillation. ## Footnote I think both MR and MS both fuck the LA (strain and dilitation) therefore causing electrical disruption and causing AF.

Question 29

TOM TIP: patient presenting with heart valve pathology

Answer 29

When examining a patient with heart valve pathology, look for signs of the potential underlying cause. For example, look for signs of infective endocarditis in a patient with mitral stenosis, such as splinter haemorrhages, Janeway lesions, Osler’s nodes and splenomegaly, and offer fundoscopy for Roth spots. Look for signs of Marfan syndrome in a patient with aortic regurgitation, such as tall stature, long limbs, arachnodactyly (long slender fingers) and a high-arched palate. This will make you look very clever.

Question 30

Define aortic stenosis

Answer 30

Aortic stenosis = narrowing of the aortic valve Restricts blood flow from LV → **aorta**

Question 31

How does the murmur that aortic stenosis causes present?

Answer 31

**Ejection-systolic high-pitched murur** - with a **crescendo-decrescendo** character ## Footnote Aortic stenosis causes an ejection-systolic, high-pitched murmur due to the high blood flow velocity through the aortic valve. This has a crescendo-decrescendo character due to the speed of blood flow across the value during the different periods of systole. Flow during systole is slowest at the start and end and fastest in the middle.

Question 32

Presentation of aortic stenosis

Answer 32

* **Ejection-systolic crescendo-decrescendo murmur** (high-pitched) → radiates to the **carotids** * **Thrill** on palpation (on aortic area) * **Narrow pulse pressure** (difference between systolic an diastolic blood pressure) * **Exertional syncope** (lightheadedness and fainting when exercising) due to difficulty maintaining a good flow of blood to the brain * **Slow-rising pulse** ## Footnote The murmur radiates to the carotids as the turbulence continues into the neck.

Question 33

Define aortic regurgitation

Answer 33

Aortic regurgitation = incompetent aortic valve - allowing blood to flow back from the **aorta** into the **left ventricle**

Question 34

What murmur does aortic stenosis cause?

Answer 34

**Early diastolic soft murmur** It can also cause an **Austin-Flint murmur**. This is heard at the apex as a diastolic “rumbling” murmur. This is caused by blood flowing back through the aortic valve and over the mitral valve, causing it to vibrate.

Question 35

Signs of aortic regurgitation

Answer 35

* **Early diastolic soft murmur** * **Thrill** on palpation (aortic area) * **Wide pulse pressure** * **Collapsing pulse** * **Heart failure** + **pulmonary oedema** ## Footnote AS → narrow pulse pressure AR → wide pulse pressure

Question 36

What is a collapsing pulse (AKA water hammer pulse)

Answer 36

A collapsing pulse or water hammer pulse is a forcefully appearing and rapidly disappearing pulse. This is typically felt in the radial artery with the patient’s arm held straight upwards. It occurs as blood is forcefully pumped out of the left ventricle, then immediately flows backwards through the incompetent aortic valve.

Question 37

What type of hypertrophy does mitral stenosis and aortic stenosis cause?

Answer 37

* Mitral stenosis → left atrial hypertrophy * Aortic stenosis →left ventricular hypertrophy ## Footnote Stenosis causes hypertrophy on the first part of the heart (A) If blood flow was from A → B

Question 38

What type of dilatation does mitral regurgitation and aortic regurgitation cause?

Answer 38

* Mitral regurgitation → left atrial dilitation * Aortic regurgitation → left ventricular dilitation ## Footnote Regurgitation causes hypertrophy on the first part of the heart (A) If blood flow was from A → B

Question 39

What effects on the heart does stenosis and regurgitation of the valves cause?

Answer 39

**Stenosis** → causes **hypertrophy** * (When pushing against a stenotic valve, the muscle has to try harder, resulting in hypertrophy) **Regurgitation** → causes **dilitation** * (When a leaky valve allows blood to flow back into a chamber, it stretches the muscle, resulting in dilatation)

Question 40

Define tricuspid regurgitation

Answer 40

Tricupsid regurgitation = incompetent tricuspid valve - allowing blood flow from **RV → RA** during **systolic contraction**

Question 41

Describe the murmur produced by tricuspid regurgitation

Answer 41

**Pan-systolic murmur** + split S2 sound ## Footnote There is a split S2 sound due to the pulmonary valve closing earlier than the aortic valve, as the right ventricle empties faster than the left ventricle.

Question 42

Signs of tricuspid regurgitation

Answer 42

* **Pan-systolic murmur** * **Split S2 sound** * **Thrill** on palpation (tricuspid area) * **Raised JVP** with **giant C-V waves** (Lancisi’s sign) * **Pulsatile liver** (due to regurgitation into the venous system) * **Peripheral oedema** * **Ascites**

Question 43

Causes of tricuspid regurgitation

Answer 43

* Pressure due to left-sided heart failure or pulmonary hypertension (“functional”) * Infective endocarditis * Rheumatic heart disease * Carcinoid syndrome * Ebstein’s anomaly * Connective tissue disorders, such as Marfan syndrome

Question 44

Define pulmonary stenosis

Answer 44

Pulmonary stenosis = narrowed pulmonary valve Restricts blood flow from RV → pulmonary arteries

Question 45

What murmur does pulmonary stenosis cause?

Answer 45

**Ejection systolic** murmur - loudest in the **pulmonary area** with deep **inspiration** There is a **widely split second heart sound**, as the left ventricle empties much faster than the right ventricle.

Question 46

Signs of pulmonary stenosis

Answer 46

* **Ejection systolic** murmur + split S2 sound * **Thrill** on palpation (pulmonary area) * **Raised JVP** with **giant A waves** (due to the right atrium contracting against a hypertrophic right ventricle) * **Peripheral oedema** * **Ascites**

Question 47

Is pulmonary stenosis congenital or acquired?

Answer 47

**CONGENITAL**!!

Question 48

What syndrome/conditions are associated with pulmonary stenosis?

Answer 48

* Noonan syndrome * Tetrology of Fallot

Question 49

What are the 4 coexisting pathologies in Tetrology of Fallot

Answer 49

* Ventricular septal defect (VSD) * Overriding aorta * Pulmonary valve stenosis * Right ventricular hypertrophy

Question 50

Complications of bicuspid aortic valve

Answer 50

* Aortic stenosis or regurgitation * Higher risk for aortic dissection and aneurysm formation of the ascending aorta

Question 51

What syndrome is associated with bicuspid aortic valve?

Answer 51

Turners syndrome (XO) ## Footnote And associated with a left dominant coronary circulation (the posterior descending artery arises from the circumflex instead of the right coronary artery

Question 52

Prosthetic aortic and mitral valve info

Answer 52

**Bioprosthetic (Biological) Valves:** * Source: bovine or porcine * Main issue: degeneration & calcification over time * Common in: older patients (>65 aortic, >70 mitral) Anticoagulation: Usually not long-term * Warfarin for first 3 months (selected patients) * Lifelong low-dose aspirin **Mechanical Valves:** * Type: mostly bileaflet (ball-and-cage obsolete) * Main advantage: low failure rate * Main issue: high thrombosis risk → lifelong anticoagulation * Anticoagulation: * Warfarin (not DOACs) Aspirin only if other indication (e.g. IHD) * Target INR: * Aortic = 3.0 * Mitral = 3.5 **Summary:** **Bioprosthetic = elderly, short-term anticoagulation Mechanical = young, durable, but lifelong warfarin**

Question 53

Super basic valvular disease

Answer 53

* **Stenosis**: struggling trying to get to **A → B** - causing **hypertrophy** * **Regurgitation**: blood flow going backwards **(B → A)** - causing **dilitation**

Question 54

Causes/associations of mitral prolapse

Answer 54

* Usually **idiopathic** (5-10% population) Associations: * congenital heart disease: PDA, ASD * cardiomyopathy * Turner's syndrome * Marfan's syndrome, Fragile X * osteogenesis imperfecta * pseudoxanthoma elasticum * Wolff-Parkinson White syndrome * long-QT syndrome * Ehlers-Danlos Syndrome * polycystic kidney disease

Question 55

What are the features of mitral prolapse?

Answer 55

* Patients may complain of **atypical chest pain** or **palpitations** * **Mid-systolic click** (occurs later if patient squatting) * **Late systolic murmur** (longer if patient standing) Complications: * Mitral regurgitation * Arrhythmias (including long QT) * Emboli * Sudden death

Question 56

Management of mital valve prolapse

Answer 56

* Asymptomatic MVP discovered incidentally with no or mild MR → requires no follow-up or treatment * **No antibiotic prophylaxis or activity restrictions are required** * Refer to cardiology if moderate/severe MR, arrhythmias, or risk factors for sudden cardiac death are present