Cardiology Review: Murmurs, Exams, Pericarditis to Atrial Fibrillation

Practice flashcards covering murmurs, exam techniques, pericarditis, myocarditis, endocarditis, rheumatic disease, and atrial fibrillation management with emphasis on clinical reasoning and exam findings.

Where are the best auscultation points for each of the four principal cardiac valves (aortic, pulmonic, tricuspid, mitral)?

Aortic: 2nd right intercostal space; Pulmonic: 2nd left intercostal space; Tricuspid: 4th left intercostal space at the lower left sternal border; Mitral: 5th left intercostal space at the midclavicular line.

What is a thrill in the cardiac exam?

A palpable vibration indicating a loud murmur, often described as a four out of six on the intensity scale.

What does a lift or heave on cardiac inspection suggest?

Ventricular hypertrophy or dilated cardiomyopathy (enlarged heart with outward displacement).

What do S1 and S2 sounds correspond to?

S1: closure of the mitral and tricuspid valves, marking the beginning of systole; S2: closure of the aortic and pulmonic valves, marking the beginning of diastole.

What is a fixed split S2 and what condition is it associated with?

A fixed split S2 is due to delayed pulmonic valve closure that does not vary with respiration, classically associated with atrial septal defect (ASD).

Describe an S3 gallop and when it is considered normal vs abnormal.

S3 occurs early in diastole as rapid ventricular filling; normal in young athletes but abnormal in adults with congestive heart failure or volume overload.

Describe an S4 gallop and its clinical associations.

S4 occurs late in diastole with atrial contraction into a stiff ventricle; associated with left ventricular hypertrophy, hypertension, post–myocardial infarction scarring.

What are functional (innocent) murmurs and who typically has them?

Murmurs due to high cardiac output (pregnancy, anemia, young athletes); no intrinsic valve pathology.

Name the four systolic murmurs you should know.

Mitral regurgitation, Aortic stenosis, Tricuspid regurgitation, Pulmonic stenosis.

What are the hallmark features of aortic stenosis on auscultation and history?

Harsh systolic murmur best heard at the right 2nd intercostal space with radiation to the carotids; may cause syncope with exertion and angina.

Describe the murmur of aortic regurgitation and where it is best heard.

Blowing, decrescendo diastolic murmur best heard at the left sternal border (Erb’s point); often with widened pulse pressure; may have Corrigan (water-hammer) pulse.

What are the characteristics of mitral regurgitation on exam?

Holosystolic murmur best heard at the apex with radiation to the axilla; possible S3; due to leaflet malcoaptation or papillary muscle dysfunction; can be due to MVP, LV dilation, ischemic heart disease.

Describe tricuspid regurgitation in terms of timing, location, and a key inspiratory feature.

Pansystolic murmur best heard at the left lower sternal border; accentuated with inspiration; associated with pulmonary hypertension, IV drug use, and Ebstein’s anomaly.

What is the hallmark murmur of pulmonic stenosis and its typical setting?

Systolic murmur at the left second intercostal space; usually congenital and may present with cyanosis in severe cases.

How is mitral valve stenosis typically caused and what is its classic diastolic finding?

Usually from rheumatic heart disease following untreated group A streptococcal infection; presents with an early diastolic rumbling murmur with an opening snap.

What is Dressler syndrome and how is it treated?

Post–myocardial infarction (or post-cardiac surgery) fibrinous pericarditis; treated with NSAIDs or high-dose aspirin and often colchicine.

What are the key features of pericardial effusion and tamponade on exam and imaging?

Fluid in the pericardial space can cause hypotension, JVD, muffled heart tones (Beck’s triad); pulsus paradoxus and electrical alternans on EKG; echo shows effusion; management may require pericardiocentesis or a pericardial window.

What is the typical presentation and diagnostic approach for myocarditis?

Viral prodrome with chest pain and dyspnea; elevated troponin; diffuse ST elevations on EKG resembling pericarditis; may progress to dilated cardiomyopathy; diagnosed with cardiac MRI and endomyocardial biopsy for etiology; treat heart failure symptoms and avoid NSAIDs.

What are the risk factors and classic features of infective endocarditis, and what is the common organism?

Prosthetic valve, IV drug use, pacemaker/ICD leads, immunosuppression, dental or surgical procedures; fever, murmur, possible glomerulonephritis; common organism: Staph aureus; diagnosed by blood cultures and echo (vegetation); treated with antibiotics for 2–6 weeks (native valve shorter, prosthetic longer).

What is rheumatic heart disease and its connection to mitral stenosis?

Result of untreated group A Streptococcus pharyngitis leading to rheumatic fever and valvular scarring; mitral stenosis is the most common rheumatic valve lesion worldwide; secondary prevention with penicillin; may require valve surgery.

How can you recognize atrial fibrillation on an ECG and clinically?

Irregularly irregular rhythm with no discrete P waves; variable R-R intervals; rate often 110–140s; assess stability and precipitating factors; risk of thromboembolism requires anticoagulation based on stroke risk (CHADS-VASc).

What are the main anticoagulation options for atrial fibrillation and when should DOACs be preferred over warfarin?

Warfarin (INR 2.0–3.0) and DOACs (rivaroxaban, apixaban, edoxaban); DOACs are preferred over warfarin when there is no moderate-to-severe mitral stenosis and no mechanical valve; adjust for renal function; warfarin remains needed for mechanical valves or significant mitral stenosis.

What is the role of cardioversion and the 48-hour rule in atrial fibrillation management?

Unstable AF requires immediate synchronized cardioversion; if AF lasts more than 48 hours, assess for atrial thrombus (TEE recommended before cardioversion) and anticoagulate for ~3 weeks prior or after, depending on rhythm strategy.

What is pulmonary vein isolation in A-fib treatment?

Catheter ablation around the pulmonary veins to isolate ectopic foci driving AF; considered for paroxysmal or persistent AF when rhythm control is desired.