Order of heart sounds
S4, S1, S2, S3
What is SBP?
pressure exerted upon the artery during heart contraction
What is DBP?
pressure exerted upon the artery wall during heart rest
When does atrial repolarization occur?
it’s hidden in the QRS complex
What side of the heart is the high pressure system?
left side (right side is low pressure)
What causes a murmur?
valve in non-compliant, incompetent, stiff, or damaged
How do we evaluate a murmur?
echocardiogram
When should you be concerned with a murmur?
when associated with symptoms (sweating, dizziness, high BP, losing consciousness…)
*pathological: LOUD heart sounds
Regurgitation
turbulent flow sound when blood is moving in an opposite direction than it should
Stenosis
turbulent flow when blood is moving through a stiff, damaged valve
Where do I listen to the heart?
Aortic (R 2nd ICS), Pulmonic (L 2nd ICS), Tricuspid (L 4th/5th ICS), and Mitral (R 4th ICS)
*All Physicians Take Money
Grade 1
soft murmur heard in a quiet place
Grade 2
soft murmur heard in noisy place
Grade 3
prominent heart murmur
Grade 4
loud murmur with a thrill
Grade 5
Loud murmur heard with edge of the stethoscope tilted against the chest and a thrill
Grade 6
Loud murmur heard 5-10mm from the chest and a thrill
*you walk into the room and hear this…super loud
RINspiration vs. LEXspiration
- inspiration, right side of heart gets louder (tricuspid and pulmonic)
- expiration, left side of heart gets louder (mitral and aortic)
Preload
volume of blood sent the heart
- increasing–> LOUDER murmur
- decreasing–>SOFTER murmur
HOCM
- increase in preload improves aortic murmur by pushing the septum away from the aortic outflow track allowing blood to be ejected more easily
- decreased preload worsens the murmur
- FH os sudden cardiac death (20-30s)
*afterload: increased (softer), decreased (louder)
Mitral Valve Prolapse
- leaflets of mitral valve prolapse into the left atria under normal pressure and blood flow
- increase in preload improves the clock heard with MVP by allowing the prolapsed leaflets to return to normal orientation
- Midsystolic “click”
- clinical presentation of a young woman with a psychiatric history
- Myxomatous valvular disease in the stem question
“See the MVP to be the MVP, and everything will click”
*afterload: increased (softer), decreased (louder)
Afterload
-pressure the ventricles have to generate to move blood forward into the arterial system
increased=louder
decreased=softer
*exceptions: MVP, HOCM (opposite)
Aortic Stensosis
- Crescendo-Decrescendo murmur
- Case presentation: Old (SAD), calcified aortic valve, radiates UP to the carotid arteries
Mitral Regurgitation
- Rheu-mitral (RHD can cause this from RF from strep)
- best heard at apex
- radiates to axilla
- holosytolic murmur (chhhh. chhh. steady kind of murmur)
