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

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. 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