Murmurs

Question 1

What are the basics identifiers of heart murmurs?

Answer 1

• Grade I-VI (II, III most common)
• Systolic vs diastolic
• Where heard best
• Does it radiate

Question 2

What are the main characteristics of aortic stenosis?

Answer 2

• Early to systolic murmur
• Crescendo-decrescendo, possible ejection click
• Heard best over base and tends to radiate to carotids
• late stages maybe have decreased systolic pressure and slow carotid upstroke

Question 3

What are the eitology, sx’s and treatment for As?

Answer 3

1. Degenerative calcific, rheumatic or congenital bicuspid
2. Angina, syncope and dyspnea on exertion SAD
3. Valve replacement, ballon valvuloplasty in children and young adults

• stenosis can cause micro-angiopathic hemolytic anemia by mechanical shearing of RBC’s

Question 4

What is the pathophys of AS?

Answer 4

Shouldn’t be a pressure gradient from LV to aorta. Thus severe dz suggest pressure gradient of over 50mmHg

• another way is valve area (1/3 valve area means severe dz)
• can lead to LV hypertrophy and HF

Question 5

how does one discriminate between AS and rheumatic Heart Dz?

Answer 5

In rheumatic the Aortic stenosis is caused by fusion of aortic valve commissures.

• AS its caused by fibrosis
• Rheumatic ALWAYS has mitral stenosis involvement with AS.

Question 6

What are some characteristics of mitral insufficiency?

Answer 6

Holosystolic “blowing murmur”

• apex and radiates to axilla
• 5th intercostal space
• Louder when squatting and expiration

Question 7

What is the etiology of MR?

Answer 7

• ACUTE RHD
• Congenital
• Acute MI with papillary muscle dysfunction
• Endocarditis
• Calcification with age
• MV prolapse
• LV dilation (pulls valve apart)

Question 8

What are some consequences of mitral regurge?

Answer 8

Left atrial enlargement and pulmonary edema

• Acute SOB
• Fatigue
• A-fib

Question 9

What is the treatment for mitral regurge?

Answer 9

Treat CHF medically and a-fib

- Surgery

Question 10

Why does squatting and expiration lead to louder MR murmur?

Answer 10

Squatting increases systemic tension and thus increases LV tension and decreased LV emptying

• Expiration moves blood from lungs to left atrium leading to increase SV

Question 11

What are some characteristics of mitral stenosis?

Answer 11

Diastolic murmur heart best at apex with patient laying on left side

• Low pitched rumble
• Opening snap
• Caused by chronic RHD and rarely congenital

Question 12

Symptoms of MS? Treatment?

Answer 12

Dyspnea with exertion and cough

• hemoptysis (bloody cough)
• Arterial embolism
• Antibiotic prophylaxis, CHF, A-fib and valve replacement is less than 1.0 cm2

Question 13

What is the pathophys of MS?

Answer 13

4-6 cm2= normal orfice

• Pulmonary HTN
• Pulmonary edema
• mural thrombi
• Left atrial pressure
• Resultant Right ventricular failure

Question 14

what are some characteristics of aortic insufficiency?

Answer 14

High pitched diastolic murmur at base

• Best heart when pt is sitting
• Water hammer pulse
• Increased pulse pressure
• Louder and longer with increased severity
• Decrescendo murmur

Question 15

What are the causes of AI?

Answer 15

• Rheumatic hd
• endocarditis
• Trauma
• Congenital (marfans) or bicuspid

Most commonly from aortic root dilation by syphilitic aneurysm or aortic dissection

Question 16

What are the sx’s and treatment for AI?

Answer 16

Asymptomatic for years

• Palpitations while laying down
• Exertional dyspnea and orthopnea
• Angina and CHF
• Increase SV
• Pulsatile nail bed
• Eccentric hypertrophy of LV

Treat: asx until myocardial dysfunction but after valve replacement myocardial dysfunction does not return

Question 17

What is mitral prolapse?

Answer 17

Mid to late systolic click (softer with squatting)

• Followed by high pitched late systolic murmur
• usually benign
• Treat with reassurance or replacement

Question 18

What are the causes and consequences of MVP?

Answer 18

Congenital or genetic
Very common
Females from 14-30.

Myxoid degeneration of posterior leaflet

• Chordeae rupture
• ED or Marfans

Question 19

What are some MVP complications?

Answer 19

• Infective endocarditis
• arrhythmias
• severe MR

Question 20

What is tricuspid stenosis?

Answer 20

Rare in developed

• Rheumatic and ass with MS
• Giant A wave in neck
• Diastolic murmur heard at lower left sternal border and xiphoid

Question 21

What is tricuspid regurge?

Answer 21

Functional from RV dilation
- Right HF
Holosystolic murmur at LLSB
Prominent V waves in neck

Question 22

How about pulmonic stenosis?

Answer 22

Preceded by ejection click

• midsystolic murmur at left 2nd and 3rd interspaces
• benign in younger people

Question 23

Innocent murmurs?

Answer 23

• Always systolic ejection in nature
• no evidence of physiologic anomalies
• Grade I or II
• No thrills or radiation
• End well before S2
• 30-50% children