Cardiac murmurs in a summary
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I made this tabulated document on Aortic Stenosis,Aortic regurgitation, Mitral stenosis & Mitral regurgitation for quick referance on every aspect in brief.
![Signs
1. pulse
Slow rising(carotid pulse)
High vol collapsing
(AS+AR= bisferious pulse)
2.BP
SBP ↓ , DBP normal (pulse P
narrow 100/90)
No change
↑ SBP , normal or ↓ DBP
(wide pulse P 170/70)
Later ↑
3.JVP
4.other
Palpation
Precordiu
m
Apex
Peripheral signs
1.De Musset’s(head nodding)
2.Light house (Face colour)
3.Müller's (Pulsating uvula)
4. Corrigan's (Dancing carotid)
5. High volume pulse
6.Hill’s (BP hand>leg)
7.Quincke’s (nail bed pulsatn)
8.Austin Flint
9. Rosenbach's sign (pulsatile
liver)
10.Gerhardt (systolic
pulsation in spleen)
11.Traube's pistol femoris )
12.Duroziez’s (femoral sys
dias murmur distaly proxim)
Brain kidney
mesenteric emboli
Low vol pulse (If
AF→irregular
irregular)
No significantchange
in BP
No change.later back
P→ ↑ JVP
Malar rash in white
skinned people.
(severe stenosis)
Displaced (volume overload)
Apex not shifted
THRUSTING
Thrill in aortic area & carotids
(4 thrills AS ,MR, VSD, Pul HT )
HOCM- double apex
No thrill
In advanced -> RVH
parasternal heave
TAPPING apex due to
loud S1.
L pparasternal heave
in back P
?valvotomy scar
? strenotomy scar
+/- Diastolic thrill at
the apex
nd
Lat and Downward
displaced.
THRUSTING (vol
overload)
Thrill
Parasternal heave in
advanced
Apex
Apex
With diaphragm. No need
of positioning or breath
holding.May hear
anywhere
[Vary according to
pathology→ Dilated
cardiomyopathy early
systolic]
Pan systolic murmur
Seated leaning forward
Breath held in expiration
Using diaphragm
Seated leaning forward
Breath held in expiration
Using diaphragm
L lateral position.
Using BELL lightly
apply. Breath hold in
expiration
Timing
Ejection Systolic
Early diastolic
Opening snap+mid
diastolic rumbling
murmur+pre systolic
accentuation (pre sys
accentuation only
heard in sinus rhythm)
Radiation
Radiate to neck (same
intensity)
Rarely to apex (Gallavardin
phenomenon)
Loudness more if severe
-
Yapa Wijeratne M/07/189
May ↑ in advanced
R 2 ICS, lower L sterna
th
border (4 Lft ICS)
Bell/diaph
ragm
Loudnness
↑/↓ .MVP: ↑
Ortner’s (cardiovocal)
sy: MS>LA
dilatation>compressio
n of L.RLN> vocal cord
paralysis>voice
change
Apex not displaced. (Pressure
overload/LVH)
SUSTAINED HEAVING.
Auscultation
nd
Site: Best
R 2 ICS
heard
Jerky pulse(not
diagnostic). can have AF
High pitched](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
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Cardiac murmurs in a summary
- 1. Feature Etiology Symptoms Aortic Stenosis Aortic regurgitation 1 .Rheumatic fever 2. Congenital bicuspid valve 3.Aortic sclerosis (not typically a stenosis) 4.Supra valvular obstruction (congenital diaphragm often associated with mental retardation & hypercalcemia William’s syndrome) Sub valvular obstruction (congenital diaphragm) 5.HOCM ACUTE AR 1.Rheumatic carditis 2.IE 3.Aortic dissection 4.Rupture of sinus of Valsalva 5.Marfan syndrome 1. Fatigue 2.Syncope( Inadequate cerebral perfusion) Giddiness >calcification of AV node>complete heart block 3.Angina if thickening involve coronary orifices (ant ,lft post cusps) 4.Dyspnoea (later) Acute- Acute heart failure , Dyspnoea, Orthopnea Yapa Wijeratne M/07/189 CHRONIC AR 1.Chronic RF 2.Bicuspid valve 3.Marfan 3.Conective tissue disorders 4.Autoimmune rheumatoid diseases 5.HTN 6.Syphilis 7.Ankylosing spondilitis Chronic- Fatigue, Syncope, angina Mitral stenosis Mitral regurgitation 1.Rhumatic fever 2.Calcification(elderly) 3.Congenital(rare) 4.Lutembacher’s syndrome (MS+ ASD)MS is often ACUTE MR 1.MI 2. Rheumatic fever 3.Endocarditis 4.Myocarditis rheumatic in origin CHRONIC MR 1.Rheumatic heart dx 2.HTN 3.Dilated cardiomyopathy 4.Rheumatoid diseases 5.HOCM 5.Carcinoid Tumor (Pulmonary carcinoidmitral diseases, Gut carcinoid ->Tricuspid diseases) Low vol output→fatigue, back P→ pul oedema→orthopnoea , dyspnoea, PND. RHF features Palpitations Ischemic emboli from MV→ Splenic infarction(LHC pain) Anatomically 1.Mitral Valve annulus: 1. Annular Dilatation(Dilated Cardiomyopathy, LVF, CCF) 2. Age related Annular Calcification 2.Leaflets: 1. Rheumatic Carditis 2. Myxomatous Degeneration 3. IE 3.Chordae Tendinae: 1. Rheumatic carditis – Fibrosis of the subvalvular apparatus 2. Chordal Rupture 3. Myxomatous Degeneration 4.Papillary Muscles: (Any condition affecting the Myocardium) 1. MI 2. Ischaemia 3. Cardiomyopathy 4. Papillary muscle rupture in MI 5. Myocarditis Hrt failure- Dyspnoea, Orthopnea, PND Back P→ RVF (congestion of liver, neck veins,leg oedema) Palpitations – AF
- 2. Signs 1. pulse Slow rising(carotid pulse) High vol collapsing (AS+AR= bisferious pulse) 2.BP SBP ↓ , DBP normal (pulse P narrow 100/90) No change ↑ SBP , normal or ↓ DBP (wide pulse P 170/70) Later ↑ 3.JVP 4.other Palpation Precordiu m Apex Peripheral signs 1.De Musset’s(head nodding) 2.Light house (Face colour) 3.Müller's (Pulsating uvula) 4. Corrigan's (Dancing carotid) 5. High volume pulse 6.Hill’s (BP hand>leg) 7.Quincke’s (nail bed pulsatn) 8.Austin Flint 9. Rosenbach's sign (pulsatile liver) 10.Gerhardt (systolic pulsation in spleen) 11.Traube's pistol femoris ) 12.Duroziez’s (femoral sys dias murmur distaly proxim) Brain kidney mesenteric emboli Low vol pulse (If AF→irregular irregular) No significantchange in BP No change.later back P→ ↑ JVP Malar rash in white skinned people. (severe stenosis) Displaced (volume overload) Apex not shifted THRUSTING Thrill in aortic area & carotids (4 thrills AS ,MR, VSD, Pul HT ) HOCM- double apex No thrill In advanced -> RVH parasternal heave TAPPING apex due to loud S1. L pparasternal heave in back P ?valvotomy scar ? strenotomy scar +/- Diastolic thrill at the apex nd Lat and Downward displaced. THRUSTING (vol overload) Thrill Parasternal heave in advanced Apex Apex With diaphragm. No need of positioning or breath holding.May hear anywhere [Vary according to pathology→ Dilated cardiomyopathy early systolic] Pan systolic murmur Seated leaning forward Breath held in expiration Using diaphragm Seated leaning forward Breath held in expiration Using diaphragm L lateral position. Using BELL lightly apply. Breath hold in expiration Timing Ejection Systolic Early diastolic Opening snap+mid diastolic rumbling murmur+pre systolic accentuation (pre sys accentuation only heard in sinus rhythm) Radiation Radiate to neck (same intensity) Rarely to apex (Gallavardin phenomenon) Loudness more if severe - Yapa Wijeratne M/07/189 May ↑ in advanced R 2 ICS, lower L sterna th border (4 Lft ICS) Bell/diaph ragm Loudnness ↑/↓ .MVP: ↑ Ortner’s (cardiovocal) sy: MS>LA dilatation>compressio n of L.RLN> vocal cord paralysis>voice change Apex not displaced. (Pressure overload/LVH) SUSTAINED HEAVING. Auscultation nd Site: Best R 2 ICS heard Jerky pulse(not diagnostic). can have AF High pitched
- 3. Character Severity Simulation Added sounds Auscultati on of other areas Other organs ECG S1-normal/low may have involved in murmur(severe murmur may mask S1) S2-Softer(nothing to close) S3-no S4 –Ten-ne-ssee heard sometimes [Aortic sclerosis- S1 S2 heard separately & murmur may not radiate] Harsh in quality S1- Normal S1- loud (stenosed) S1-soft S2- Normal S3- may heard due to LV vol overload (kentaki) S2-Not affected? just before opening snap S3Pre sys accentuatn S2- [Dilated CM-S2 clearly heard. MVP- S1 heard] 1.Ejection click 2. LVH therefore @ end of diastole atrial systole against hypertrophied LV can give S4 in apex with the bell turning to left Tu faaaav Austin Flint- Regurgitant vol hit on ant leaflet of MV give mid diastolic murmur @ apex Pul oedema- basal crepts [severity high –if Murmur is prolong, Opening snap closer to S2] Tum tharaaaaF Back pressure→ S2-loud(pul HT) Pul oedema –B crepts Graham Steele- pul regurg 2ry to pulm artery dilatation caused by ↑pulm a P in MS TR- systolic murmur S3- can present (Kentuck-y) Tufaaaaaaaaav (1 sound) Can hear pan sys murmur anywhere. Apex ,L sterna area, Back of chest, Axilla Usually not LVH sometimes arrythmia Tall R in v5,v6→LVH Asymetrical T inversion – LV strain P mitrale Left axis deviation Complete Heart Block – calcification of AV node Liver spleen pulsating with systole. Lung –pul oedema Back pressure- RVF ankle oedema, liver congestion LVH Lungs – pul oedema In severe- back P-> features of RHF AF/Atrial Flutter, P mitrale. When severe RVH(Rt axia deviation+perhaps tall R waves in V1) & RV strain If AF: -No P waves -Fibrillatory waves (irregular baseline) -R-R interval irregularly irregular If in sinus rhythm: P mitrale (S shaped/Biphasic) – in V1 – due to LA dilatation Bifid P – in L II – due to Biatrial dilatation RV Hypertrophy and RV strain– tall R in V1-V3, inverted T Left axis deviation (LV volume overload) Right axis deviation (RV hypertrophy in PHT) Features of left atrial delay (bifid P waves) & LVH (tall R waves in the left lateral leads (e.g. leads I and V6) & deep S waves in the rightsided precordial leads, Yapa Wijeratne M/07/189
- 4. CXR Normal heart in CXR or Cardiomegaly-LVH Calcification of aortic valve may be seen. Post stenotic dilatation may be seen Cardiomegaly Aortic valve calcification Pul oedema Post valvular dilatation of aorta (commonly seen in syphilitic aortitis) 1.Normal apex 2.LAH(straight L border) 3.LA enlarges toward R side -> double atrial shadow 4.calcific MV 5.Pul oedema (Large pul artery, Bats wing, Kerly B, fluid in horizontal fissure,Pulmonary congestion, Upper lobar venous diversion Mx Aortic valve replacement – Rx of choice ( before the pt becomes symptomatic) Balloon aortic valvular plasty palliative If Angina present→ angiogram→ CABG if necessary ACUTE-Aortic valve replacement-definitive therapy CHRONICDrugs to control heart failure diuretics anti HT etc.. In severe conditions valve replacement Angiogram – perform CABG if CAD is detected Less symptomatic→ observe Developing complications→ drugs Pul HT- Diuretics Sinus tachycardiaBeta Blockers,Digoxin AF-rate control – Beta blockers, Digoxin. rhythm control Amiodorone Complications: Heart failure Infective endocarditis Yapa Wijeratne M/07/189 Symptomatic -> Sx 1.PTMC (percutaneous trans septal mitral comissurotomy) 2.Closed valvotomy 3.Open valvotomy 4.MV replacement (e.g. leads V1 and V2). (Note that SV1 plus RV5 or RV6 >35 mm indicates LVH.) LVH occurs in about 50% of patients with MR. Cardiomegaly MV calcification Double atrial shadow Pul oedema Upperlobar venous diversion – first sign of heart failure in CXR Chronic- Don’t need, only symptomatic treatment. Acute- MV replacement AF – Digoxin Pulmonary oedema Frusemide (& K suppliments) -K sparing Diuretics Severe MR – Mitral valve surgery ( mitral valve repair or mitral valve replacement) [NEED SABE PROPHYLAXIS {Clindamycin} in tooth extraction, skin piercing etc]