Valves and murmurs

these legit all sound the same to me. turn up fam

echo

For basically EVERY murmur what is the diagnostic test?

mitral, tricuspid

What valves close at S1

systole

S1 (lub) is the beginning of

atrial kick (gallop)

What is S4

blood hitting a noncompliant LV

What causes an S4 (be lub dup - Tennessee, heard every beat)

aortic, pulmonic

What valves close at S2

diastole

S2 (dub) marks the beginning of

ventricular gallop

What is an S3

blood striking a very compliant LV

What causes a S3 (lub dub dub - kentucky, heard every 3 beat)

RBBB, pacing from electrode on LV, PVCs, ASD, ebstein’s anomaly, triscuspid stenosis

What may cause a S1 split

inspiration increases venous return, delayed closure of pulmonic valve

How does a physiological S2 split occur

Severe HCOM, aortic stenosis, LBBB, severe HTN

What might cause a paradoxically split S2

S2 splits on expiration, together on inspiration

Describe a paradoxically split S2

ASD (prolonged RV systole)

Wide, fixed splitting (no respiratory variation) is a characteristic of

RBBB (increased RV systoles) mitral regurg, VSD

Wide, fixed that varies with inspiration is a characteristic of

best heard over apex in left lateral position, softer during inspiration

If S3/S4 is originating from the LV…

best heard over LLSB, tricuspid, subxyphoid, louder during inspiration

If S3/S4 is originating from the RV…

healthy child, athletes, hyperkinetic states, third trimester

Where might you find a normal S3

increased atrial pressure/flow rate, CHF, dilated cardiomyopathy

What might causes a pathologic S3

Apex with patient in left lateral decubitus position

Where is a S4 best heard?

AMI, ischemic cardiomyopathy, HTN, hypertensive heart, aortic stenosis

What causes an S4

Ejection click

What is the most common early systolic sound that results from the abrupt halting of aortic and pulmonic valves

loud high frequency sound, doesn’t vary with respiration, best heard at apex

Characteristics of aortic ejection click

aortic stenosis, bicuspid aortic valve, dilated aortic root

What is associated with an aortic ejection click

Opening snap

What high frequency early diastolic sound is due to an abrupt deceleration of mitral leaflets and often diminishes with inspiration?

left lateral position between apex and LLSB (closer to S2)

Where are opening snaps best heard

high frequency noise (scratchy, grating, squeaking) loudest in systole, but present in diastole as well, loudest at LLSB and during inspiration

Describe a pericardial friction rub

location, involved structure, systolic/diastolic, timing, volume/intensity, quality, pattern, radiation, special maneuvers

How are murmurs often described

moves aortic valve closer (good for aortic valve and pericarditis)

How does leaning forward affect the heart sounds

moves LV close to chest wall (good for S3, S4, mitral valve)

How does the left lateral decubitus position help murmurs

increases HCOM, decreases aortic stenosis, mitral valve prolapse moves closer to S1

How does standing affect heart sounds

increases venous return and peripheral vascular resistance, decreases HCOM, increases aortic stenosis, mitral valve prolapse moves closer to S2

How does squatting/leg raises effect heart sounds

increases regurg murmurs, VSD, S3, S4, aortic insufficiency (increases peripheral vascular resistance)

How do isometric hand grips effect heart sounds

increase HOCM, decreases aortic stenosis, mitral valve prolapse moves closer to S1 (decreases venous return)

How does valsalva effect heart sounds

increases tricuspid regurg, decreases mitral regurg, physiologic split of S2 (increases venous return to right side)

How does inspiration effect heart sounds

pregnancy, IV hydration, stress on body

What might cause a innocent systolic murmur

1-2/6 best heard at Erbs, louder when supine, disappears when sitting/standing, no radiation

Describe the typical still/flow murmur

Aortic stenosis

An obstruction of the flow of blood from the LV to the aorta typically caused by calcification of a congenital biscuspid valve, age related calcification of a valve, rheumatic disease

increased age, bicuspid aortic valve, HTN, elevated LDL, male, smoking, rheumatic valve disease

Risk factors for Aortic stenosis

dyspnea on exertion, angina, syncope, CHF symptoms

Symptoms of Aortic stenosis

harsh/grunting crescendo-decrescendo ejection murmur best hear at RUSB that radiates to the sternal notch/right carotid, S4, trill, LV heave, paradoxical split 2 are also present. Increases with squats, sitting up. Decreases with standing and valsalva

Describe the murmur of Aortic stenosis

valve replacement (aortic ballon valvotomy)

Treatment plan for aortic stenosis

Mitral valve prolapse

A congenital condition in which the mitral valve leaflets close above the annular plane during systole may promote mitral regurg

idiopathic, Marfans, familial MVP, MI, rheumatic injury, OSA, ankylosing spondylitis

Etiology of Mitral valve prolapse

tall thin body, increased catecholamines, dehydration, fam hx, Mg deficiency

Risk factors of Mitral valve prolapse

High frequency mid-systolic ejection click at LLSB that is late to holosystolic and radiates to axilla. S3, thrill, laterally displaced PMI are also present. Heard earlier in systole and louder when standing and valsalva. Decreased with squats, pregnancy, laying supine

Describe a Mitral valve prolapse murmur

beta blockers, surgical repair (with any symptoms)

Treatment plant for Mitral valve prolapse

Mitral regurg

A valvular disorder involving mitral leaflets, annulus, chordae tendineae, and papillary muscles resulting in abnormal leaking of blood across the mitral valve

MVP, rheumatic heart disease, infective endocarditis, trauma, drug induced, congenital, ischemic heart disease, non-ischemic LV systolic dysfunction, HCOM

Causes of Mitral regurg

asymptomatic, exertional dyspnea, fatigue, new onset a.fib,

Signs and Symptoms of Mitral regurg (depends on severity)

Blowing and high pitched murmur at LLSB late to holosystolic that radiates to axilla, back, and RUSB. S3, thrill, and laterally displaced PMI are also present. Increased with handgrips, decreased with Valsalva

Describe the murmur of Mitral regurg

hydralazine, nitroprusside

Treatment plan for mitral regurg to decrease afterload as a bridge to surgery

severe chronic murmur, abnormalities in LV size/function, pulmonary HTN, new onset a.fib

Indications of surgical repair of Mitral regurg

Soft mid-systolic murmur at LLSB that radiates to sternal border. Paradoxically split S2, S4 are also present. Increased by Valsalva and standing; decreased by squatting

Describe the murmur in HCOM

Holosystolic murmur at LLSB that increases with inspiration. Heading bobbing, pulsating eyes and neck are also present.

Describe the murmur in Tricuspid regurg

treat Right sided HF

Treatment for triscuspid regurg

Harsh ejection murmur at LUSB that radiates to the left clavicle. Thrill, RV heave, and widely split S2. Increases on inspiration

Describe the murmur in pulmonic stenosis

pathological

Say it with me now, Diastolic murmurs are ALWAYS

Blowing/descendo diastolic murmur best heard at Erb’s/RUSB associated with a diastolic rumble (Austin flint)

Describe the murmur in aortic regurg

ACEI, CCBs, if LV dilatation is BAD or LV dysfunction if evident (EF lower than 50%) then surgery

Treatment plan for aortic stenosis

rheumatic fever, infective endocarditis, congenital, chronic valvulitis, rheumatoid arthritis,

Causes of mitral stenosis

Low rumbling mid-diastolic decrescendo-crescendo at LLSB precede opening snap precedes murmur

Describe the murmur in mitral stenosis

anticoags (if a.fib), diuretics, percutaneous mitral balloon valvotomy (symptomatic peeps)

Treatment plan for aortic stenosis

Soft, high pitched mid diastolic rumble at LLSB preceded by an opening snap and increased with inspiration and leg raising

Describe the murmur in Tricuspid stenosis

High pitched, early diastolic decrescendo murmur at LUSB that begins with an accentuated P2 component of S2. Increased with holding breath, upright position

Describe the murmur in pulmonic regurg

fixed/split S2, midsystolic pulmonary flow/ejection murmur (big shun), mitral regurg (ostium primum), MVP (secundum)

Describe the murmur in ASD

harsh holosytolic murmur at LLSB

Describe the murmur in small VSD

harsh holosytolic murmur at LLSB with a thrill, apical impulse with lateral displacement, increased P2, diastolic rumble

Describe the murmur in moderate VSD

harsh holosytolic murmur throughout precordium with diastolic rumble at apex, precordial bulge

Describe the murmur in large VSD

washing machine over left scapula and left infraclavicular area

Describe the murmur in PDA