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Heart Murmurs (Boards and Beyond) (Clues to diagnosis (not murmurs) (MVP…
Heart Murmurs (Boards and Beyond)
caused by turbulence
grading system
I-barely audible
II-faint but easily audible
III-loud and easily audible, no thrill
thrill- vibration felt on pt chest
IV-loud murmur with a thrill
V-heard with scope barely touching chest
VI-audible with scope not touching chest
other descriptors
Holosystolic (Pansystolic)
Crescendo
rising in volume
Decresendo
dropping in volume
Crescendo -decrescendo
intensity rises/falls during cardiac cycle
Locations
RUSB- for aortic stenosis
LUSB- pulmonic murmurs, Patent ductus arteriosus
Continuous Machine-like murmur
present in systole and diastole
conduit of PDA is from aorta to pulmonary artery. Pressure does not swing up ad down, always a driving force present
LSB (Erbs point) -aortic regurgitation, hypertrophic cardiomyopathy
LLSB- Tricuspid murmur, VSD
Apex-mitral listening point
mitral murmurs
PMI
a lateral shift implies enlarged heat
Hyperdynamic- more forceful in exercise or SNS stim
Innocent murmurs
normal
in children
thin patients
Soft murmurs I or II
Stills murmur
Pulmonic flow murmur
Venous hum
Pathologic murmurs
most important: does murmur occur in systole or diastole
Systolic
between S1 and S2
Aortic Stenosis
aka "ejection murmur"
classic findings for severe disease
Late peaking murmur
slow flow across stenotic valve
Soft/quiet S2
stiff valve can't slam shut
Pulsus parvus et tardus
weak and small carotid pulses
delayed carotid upstroke
Mitral Regurgitation
best heard at the apex
Pulmonic Stenosis
Tricuspid Regurgitation
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Hypertrophic Cardiomyopathy HCM
same murmur as AS
differentiated by maneuvers
Valsalva
decreases venous return/preload
increases murmur of HCM
decreases AS murmur
VSD
holosystolic similar to MR
these 3 are all holosystolic
smaller the VSD, more turbulence = louder murmur
eg. pt w/ no symptoms but a loud murmur = small VSD
Can be normal sounds
Diastolic
between S2-S1
Aortic Regurgitation
decrescendo, blowing diastolic
Mitral Stenosis
rumbling murmur
preceded by an opening snap
there are no L sided S3, S4 in mitral stenosis
rather these are caused by rapid filling of the L ventricle in diastole, can't happen in mitral stenosis and there is a decrease in blood flow
Time to opening snap assd. w/ severity of MS, it moves closer to S1
reason: mitral stenosis increases P in LA, pushing leaflets of mitral valve open more quickly
Pulmonic Regurgitation
sound like L sided counterparts
Tricuspid Stenosis
sound like L sided counterparts
Always Pathologic
Carvallo's Sign
for distinguishing L and R sided murmurs
Inspiration decr venous return, dropping inter thoracic pressure, transmitted to RA, RA P falls and more blood enters RA
rIght-sided murmurs increase w/ INSPIRATION: R sided murmurs get louder
Inspiration holds more blood vol in the lungs, decreases flow to L heart
softer L sided murmurs
lEft sided murmurs increase w/ Expiration
Remember: Inspiration draws blood volume into the lungs, pulls blood thru the R side of the heart
Maneuvers
bedside maneuvers used to incr/decr murmur
Increasing Preload/venous return
Leg raise
blood falls back to heart
Squatting
veins in leg are compressed sending blood to heart
Valsalva
raises intrathoracic pressure, compresses veins, decreases preload, decreases VR
will see a change in murmur intensity
pt bears down as if taking a dump/ blow out with mouth closed
Phase 1 begins (lasting seconds)
thoracic pressure rises
compresses veins in thorax, sending blood to RA, RA pressure rises
Since RA pressure is higher than venous pressure, decrease in venous return
second effect: transient rise in aortic pressure
caused by compression of aorta
reflex bradycardia and decreased AV conduction via Baroreceptors
useful for breaking some types Tachycardia
Phase 2 begins
fall in preload in LV due to drop in venous return
lowers CO, lowering blood pressure (opposite of phase I)
Baroreceptors sense low BP and reflex tachycardia and AV node conduction
Standing
gravity holds blood from heart
Rx: Amyl Nitrate
decreases after load: vasodilator
Afterload maneuvers
Hand grip
clenching fist increases Afterload
Backward Valve Disorders
AR
MR
VSD
Louder with more afterload
more blood pushing blood backwards
Forward Valve Disorders
MS
AS
Softer with more afterload
afterload resists forward pressure, softer sound
MVP, HCM
Softer with more afterload
raising afterload increases LV size slightly, decreases intensity of these murmurs
Most murmurs INCREASE w/ more Preload
exceptions
HCM
MVP
Clues to diagnosis (not murmurs)
MVP
Young female otherwise healthy
HCM
Healthy young athlete w/ syncope
Mitral Stenosis
Immigrant or pregnant
3rd world countries w/ limited antibiotics for strep
blood volume increases in pregnancy making asymptomatic mitral stenosis symptomatic
Tricuspid Regurgitation
IV drug user
MVP
Marfan
Bicuspid Aortic valve
Turner Syndrome
Aortic regurgitation
Turner Syndrome
Early stenosis
Turner Syndrome
Summary
