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Overview of heart murmurs

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Summary of different heart murmurs and their features for medical finals.

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Overview of heart murmurs

  1. 1. Timing of Murmur Heart sounds Heaves Thrills Apex Pulse Aortic sclerosis * Senile calcification of aortic valve * Ejection systolic murmur * normal * none Aortic stenosis * Senile calcification * Bifid valve * William's syndrome * Rheumatic heart disease * DD hypertrophic cardiomyopathy * > 60y * Late! * Triad of: angina, dyspnoea, syncope * symptoms of LVF (PND, orphopnoea, frothy sputum) * Arrhythmias * Ejection (crescendo) systolic murmur * S1 normal * Quiet S2 or inaudible * S2 splits as stenosis worsens as A2 closure increasingly delayed * +/- ejection click * +/- S4 * Heaving apex * LV heave * Aortic thrill * Heaving but not displaced * Slow rising * Narrow PP * 2nd RICS * Carotid A * Pressure overload * LVH * Angina/syncope * Cardiac failure if untreated * ECG * Echo for gradient, vavle area, jet velocity * Cardiac catheter vor valve gradient, LV function, CAD * Medical: treat RF, causes and CHF * Surgical: (if severe or symptomatic as then prognosis poor): valve replacement, balloon valvuloplaty or TAVI if unfit Aortic regurgitation * Senile calcification * Bicuspid valve * Endocarditis * Rheumatic heart disease * Marfan's * EHD * Aortic dissection * Idiopathic root dilatation * Chest trauma * Takayasu arteritis, syphilis * SLE, seronegative arthritides * Pseudoxanthoma elasticum Drugs (appetite suppressants) * HTN * Osteogenesis imperfecta * Late! * Dyspnoea (pulmon. oedema), orthopnoea, PND * Arrhythmias, syncope * Angina * CCF * Corrigan's sign (marked carotid pulsation) * deMusset sign (heart nodding with every beat) * Quincke's sign (pulsations in nail beds) * Duroziez's sign (systolic murmur in groin when compressing femoral artery) * Traube's sign (pistol shot murmur over femoral arteries) * Sings of underlying disease * Early diastolic (decrescendo) murmur * Blowing quality, high pitched * +/- systolic flow murmur * +/- Austin Flint murmur (like MS), if severe! * Displaced * Hyperdynamic * Collapsing (water hammer) * Wide PP * 3rd LICS * Between R carotid and apex / L sternal border * Volume and pressure overload * ECG LVH * CXR cardiomegaly * Echocardiogram * Cardiac catheter * Medical: ACEi to reduce HTN * Monitor by echo/6m * Surgical: valve replacement if acute of >5.5cm dil or LV impairment (<55% ejection fxn) or symptomatic or enlarging heart or deteriorating ECG * Aim to replace valve before LV dysfunction Mitral stenosis (note: can coexist with regurgitation. Distinguish by pulse volume and LVH) * Rheumatic fever is the only acquired cause? * Congenital * Mucopolysaccharidoses * Endocardial fibroelastosis * Malignant carcinoid * Prosthetic valve * Symptoms onset when diameter <50% * Dyspnoea from pulmonary oedema * Chest pain * Chronic bronchitis-like picture * Complications: Haemoptysis, AF => stroke/embolisation, arrhythmias * OTHER SIGNS - Malar flush - Dilated capillaries - P mitrale (bifid p-wave) in early ECG - Signs of pulmonary hypertension and RHF if severe * Mid-diastolic rumbling murmur * The longer the murmur the more severe * Murmur may be following an opening snap in early diastole, sounds like a split 2nd sound with a much wider gap * The close the opening snap is to S2 the more severe * +/- Graham Steel murmur (early diastolic murmur due to pulmonary regurgitation from pulmonary HTN) * There may be pre- systolic/late diastolic accentuation which disappears when effectiveness of atrial contraction decreases * If there is prolapse => midsystolic click * Palpable S1 * Loud S1 unless valve rigid * If severe loud S2 due to pulmonary hypertension? * Palpable S1 * Tapping * Irregular * Between apex and L lateral sternal border - * Pressure overload? * Does not affect LV, LA only! * ECG: p mitrale (bifid), AF, RVH, progressive RAD * CXR: LA enlargement, pulmonary oedema, mitral valve calcification * Echocardiography is diagnostic: significant if <1cm^2 * +/- cardiac catheterisation * Medical: rate control (important!), anticoagulation for AF, diuretics * Surgical: If severe or acute and ventricular impairment. Balloon valvuloplasty or valve replacement. Abx prophylaxis for GI procedures (prevent IE) or recurrent rheumatic fever. Mitral regurgitation (Note: MR causes flow into atrium and FORWARDS into LV and aorta => LV NOT protected) * Elderly: annular calcification (=> CXR) * Papillary muscle dysfunction or ruptured cordae tendinae (MI/ischaemia) * Dilatation of the mitral ring in LHF/LVH or LV dilatation * Mitral valve prolapse * Endocarditis * Rheumatic fever * Marfan/Ehler's Danlos * Cardiomyopathy * Congenital as part of other cardiac malformations * Appetite supressants * Dyspnoea from pulmonary oedema * Symptoms of RHF * Palpitations (AF) * Systemic emboli * Infectice endocarditis (Ventricular contractility initially hyperdynamic, then ventricular dysfunction.) * Pansystolic * Prolapse may cause late systolic click * Soft S1 * Split S2 * Loud S2 (pulmonary HTN) * +/- S3 from rapid ventricular filling * RV heave * May be palpable as thrill * Displaced (the more severe, the more displaced / large the LV) * Hyperdynamic * Apex * Left axilla * Volume and pressure overload!? * Since there is also "forwards" regurgitation into LV and aorta, there is LVH * ECG: AF +/- p mitrale, LVH * CXR: LA AND LV enlargement, mitral valve calcification, pulmonary oedema * Echocardiography to assess LV function and aetiology * Cardiac catheterisation * Medical: rate control if required, anticoagulation for AF, diuretics for symptom control * Surgical: if severe or acute and ventricular impairment or deterioration. Abx prophylaxis for GI procedures (prevent IE) * Note: the mitral valve is the only valve suitable to consider repair, the aortic valve always needs replacement. Mitral valve prolapse * +/- ASD, PDA, cardiomyopathy, Turner's, Marfan's, osteogenesis imperfecta, pseudoxanthoma elasticum, WPW * Asymptomatic * Atypical chest pain and palppitations * +/- autonomic dysfunction (anxiety, syncope, panic attacks) * Mid-systolic click * Late diastolic murmur * MR * Cerebral emboli * Arrhytmias * Sudden death * ECG: T-wave inversion * Echocardiography is diagnostic * b-blockers for palpitations and chest pain * Rest as in MR Pulmonary stenosis * Maternal rubella * Turner's, Noonan syndrome (Turner-like phenotype), William's, TOF * Rheumatic fever * Carcinoid syndrome * Dyspnoea * Fatigue * Oedema * Ascites * Large A-wave in JVP * Dysmorphic facies if syndromic * Ejection systolic murmur * Potential ejection click * S2 quiet (if severe) * S2 widely split * Parasternal heave from RVH * 2nd LICS * To the back / left shoulder * ECG: p pulmonale, RVH, RBBB * CXR: prominent pulmonary arteries * Echo * Cardiac catheterisation is diagnostic * Surgical: pulmonary valvuloplasty or valvotomy Pulmonary regurgitation * Pulmonary HTN * Signs of pulmonary hypertension * Decrescendo diastolic murmur (1st half) = Graham Steel murmur, can also be resulting from MR causing pulmonary HTN) * Accentuated by inspiration * Compared to AR the sound is harsher and better heard with the bell * Left sternal border * ECG * CXR * Echo Murmur of Cause Symptoms (and signs not mentioned elsewhere) Signs Position (loudest) Radiation Consequences Ix ( ALWAYS ECG CXR ECHO!) Management
  2. 2. Pulmonary hypertension * 1* * LHF * Chronic lung disease: COPD, bronchiectasis, fibrosis, asthma, resection * Pulmonary vascular disorders: PE, vasculitis, ARDS, sickle cell, parasites * Thoracic cage malformations * MG, polio, MND * Sleep apnoea * Dysponea * Fatigue * Syncope * Cyanosis * Tachycardia * Raised JVP with prominent a and v waves * Hepatomegaly * Oedema * Pansystolic murmur from tricuspid regurgitation * Graham steel murmur from pulmonary regurgitation * Loud S2 * RV heave * FBC (2* polycythaemia?) * ABG * CXR: R heart enlargement, prominent pulmonary arteries * ECG: p pulmonale, RAD, RVH/stain * Treat cause * Treat resp. failure * Treat cardiac failure: diuretics * Venesection if polycythaemia * Heart-lung transplantation Tricuspid stenosis * Rheumatic fever * Infective endocarditis * Congenital * Rarely isolated, usually including aortic or mitral valve disease * Fatigue * Ascites * Oedema * Giant A wave of JVP, prominent Y descent * Early diastolic murmur * +/- opening snap * Left sternal edge * ECG * CXR * Echo * Medical: diuretics * Surgical: repair Tricuspic regurgitation * Dilatation of the tricuspid valve ring in RVF, e.g. due to LVF and 2* pulmonary HTN * Rheumatic fever * Endocarditis in IVDU * Carcinoid heart disease * Congenital: ASD, AV canal, Ebstein's anomaly) * Dtugs: ergot-alkaloids, fenfluramine * Giant V wave of JVP, prominent Y descent * Enlarged liver with systolic pulsation = pulsatile hepatomegaly, jaundice, ascites * Sings of RHF * Systolic brief rumbling diamond shaped or rectangular pansystolic murmur * RV heave * Marked pulsation at L lower sternal edge due to RVH) * Loudest on R costal margin * ECG * CXR * Echo * Treat underlying cause * Medical: diuretics, digoxin, ACE-i * Surgical: 10% 30d mortality! ASD * Ostium secundum defect (most common) * Ostium primum defect and associated AV valve abnormalities * Secundum defect presents late in adulthood, e.g with augmented L-R shunting in HTN * Dyspnoea * Heart failure * Pulmonary HTN * Cyanosis * Arrhythmia * Haemoptysis * Chest pain * Migraine * AF * Raised JVP * Pulmonic systolic murmur due to increased flow through the pulmonary valve * Pulmonary HTN may cause pulmonary or tricuspid regurgitation * Fixed split S2 * Eisenmenger's syndrome due to reversal of the L to R shunt by pulmonary hypertension => cyanosis * Paradoxical emboli * ECG: RBBB, LAD, long PR (primum), RAD (secundum) * CXR: small aortic knuckle, progressive atrial enlargement * Echo is diagnostic * Cardiac catheterisation: O2 sats high in R heart * In children: closure before 10y * In adults: if symptomatic * Technique: transcatheter rather than surgical VSD * Congenital * Acquired post-MI * Severe heart failure in infancy * Incidental finding * +/- signs of pulmonary hypertension * Harsh pansystolic murmur (smaller holes give louder murmurs!) * +/- L parasternal heave * Systolic thrill * L costal margin * AR * Infundibular stenosis * Eisenmenger complex * ECG: normal to LAD, LVH, RVH * CXR: cardiomegaly if severe * Echo * Cardiac catheterisation: O2 sats high in R heart * Conservative awaiting spontaneous closure * Surgical if failed medical therapy or symptomatic, IE/SCE PDA * Hypoxia in newborns * Prematurity * Iatrogenic (prostaglandins) * Dyspnoea * Tachycardia * Cyanosis (of the lower extremities) * FFT * Continuous machine-like murmur * L subclavicular thrill * Bounding pulse * Large pulse pressure * L clavicle * ECG * CXR: cardiomegaly * Echocardiogram * Conservative: waiting for closure * Medical: NSAIDS: indomethacin * Surgical: endovascular coiling or ligation Coarctation of the aorta (Most common just distal to origin of L subclavian) * Associated with bicuspic aortic valve, Turner's * Radiofemoral delay * Weak femoral pulse * HTN un upper circulation * Scapular bruit * Loud rough systolic murmur * Max over L lung anterior and posteriorly or L scapula * Heart failure * IE * CT/MRI-angiogram * CXR: rib notching * Surgical or balloon dilatation +/- stenting Pericardial friction rub * MI * Pericarditis: infectious, vascular, inflammatory, endocrine, neoplastic, traumatic, iatrogenic * Trauma * Autoimmune * Chest pain on lying flat, relieved on sitting forward * Pyrexia * 2 diastolic: when ventricles are stretched at beginning and end * 1 systolic: anywhere * High frequency murmur best heard with diaphragm * L lateral sternal border * Pericardial effusion => tamponade * Constrictive pericarditis * FBC, ESR/CRP, U&E, TFT, cardiac enzymes * ECG: saddle-shaped ST elevation +/- PR depression * CXR to rule out tamponade * Analgesia: NSAIDs * Treat cause * +/- diagnostic or therapeutic pericariocentesis Bacterial endocarditis * Note: murmurs can be mimiced by atrial myxoma * Risk factors: prosthetic valves or valvulopathy or other structal abnormality of the heart, previous rheumatic fever, IVDU, immunocompromise, DM, surgery => bacteraemia * Fever * Rigors * Night sweats * New or changing existing murmur, e.g. regurgitation * FBC, ESR/CRP * 3x blood cultures * Urine dipstick: microscopic haematuria * serology * ECG: AV block * Echo: vegetations * Empiric Abx followed by definitive * May require later surgical treatment of heart failure / valvular pathology MI * Plaque rupture + thrombosis * Embolus * Vasospasm * Vasculitis * Chest pain radiating to L arm or jaw or epigastrium * Dyspnoea * Palpitations * Anxiety * Sweating * Pallor * Vomiting * Silent: confusion/delirium, syncope, hypotension, stroke, post-op oliguria * Can present with pansystolic murmur of VSD due to ventricular rupture or pansystolic murmur of mitral regurgitation. * Can have S4 or S3 if heart failure * ECG * FBC, U&E, glucose, lipid profile, clotting * Troponin * CXR: cardiomegaly, pulmonary oedema, aortic rupture * MONABASH Morphine and metoclopramine Oxygen Nitrates Aspirin, clopidogrel Beta-blocker Ace-inhibitor Statins Heparin
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Summary of different heart murmurs and their features for medical finals.

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