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Cardiology - Heart Sounds and Murmurs (*Murmurs and Gallops (dropped image…

- - - - Systolic Murmurs
        
        Aortic Stenosis and Mitral Valve Prolapse big ones
        
        Tricupsid Regurge with IV drug users
        
        *Tricuspid Regurgitation
        
        RHEUMATIC fever
        
        Wanna TRI some drugs? ---> IV drug users affect right side of the heart
        
        secondary to decompensated heart failure and dilatation of papillary muscles
        --> pull the valve open
        
        IV Drug Users and Tricuspid Valve Disease
        
        Wanna TRI some drugs? ---> IV drug users affect right side of the heart
        
        Loud Holosystolic Murmur
        
        cause = VSD
        
        heard over the lower left sternal border
        
        VSD and Loud Holosystolic Murmur
        
        Clinical Case
        
        Notes:
        
        note that VSD = ventricular septal defect has a loud systolic murmor heard over the left lower sternal border
        
        this makes sense as each systole there is a loud rumbe of blood that goes through the left to right ventricles
        
        compare this to the splitting of S2 heard in ASD, more to do with the blood volume
        
        Normal Blood Oxygen levels in the chambers of the heart
        
        *Aortic Stensois
        
        3 common types and causes
        
        1 = congenital = bicuspid valve (with calcification)
        
        2 = Rheumatic heart Disease = RHD (M > A >T order of valves affected)
        
        3 = calcification from aging --> necrosis of endocardium --> calcified fibrosis
        
        Epidemiology of Aortic Stenosis
        
        worldwide vs western countries
        
        note that most cases of AS worldwide are from RHD
        = but in Western countries most common is Calcification of oth bicuspid and aging valves
        
        Calcified Aortic Valve Disease
        
        most common cause of aortic stenosis
        
        happens average age = 60 years old
        
        Notes:
        
        note that calcification of aortic valve that causes aortic stenosis is the same process that causes atherosclerotic plaques
        
        there is the same cause of turbulent flow, smoking, and mechanical damage
        
        these allow FFAs and cholesterol to enter the endothelium
        
        inflammation with inflammatory cells causes remodelling
        
        here fibroblasts turn into osteoblast like cells and lay down bone extracellular matrix
        --> calcification of the valves
        
        Aortic Stenosis + A Fib = Sudden Heart Failure
        
        reduced filling of the LV gives HF
        
        need cardioversion
        
        Bicuspid Aortic Valve Disease
        
        leads to aortic stenosis in >50% of patients
        
        average onset of A stenosis = 50 (10 years earlier)
        
        *Mitral Regurgitation and Prolapse = MVP
        
        "RHEUMitral Regurge FEVERS / rhD"
        --> RHD and R Fever cause MAT regurge, then chronic stenosis
        
        *MVP = Mitral Valve Prolapse
        
        "MVP players need to CLICK to win"
        --> MVP has a midsystolic CLICK
        --> the faster the onset of the click, the worse the MVP
        
        MVP CLICK = chords are too loose and suddenly pulled tight
        --> think of MVP as the chords are flopping in the wind
        --> better if the LV is more full of blood to hold them tight
        --> get MVP if there is LV hypertrophy since there is less space in the LV and the chords are too loose
        
        MVP is better on Squatting
        --> increased Venous return
        --> expands the LV and pulls chords tight
        
        MVPs LIKE to SQUAT
        
        *Mitral Regurgitation and Prolapse = MVP
        
        "RHEUMitral Regurge FEVERS / rhD"
        --> RHD and R Fever cause MAT regurge, then chronic stenosis
        
        Hemodynamics of MR
        
        1 more item...
        
        Clinical cases
        
        Clinical Case
        
        4 more items...
        
        Mitral Regurge secondary to Decpmpensated Dilated HF
        
        Secondary since the dilataion of the left ventricle causes the papillary muscles holding the valve in place to be pulle open
        
        Causes of Rheumitral Regurge
        
        think of the valve in terms of 4 parts
        
        1 = annulus = outer ring of the valves in the left atrium
        
        2 = valve leaflets
        --> RHD and R fever
        
        3 = chordae tendinae
        --> can rupture post 3-5 days MI
        
        4 = MV papillary muscles
        --> can be affected by ischemia from MI
        
        *Mitral Regurgitation
        
        "RHEUMitral Regurge FEVERS / rhD"
        
        RHEUMitral Regurge = RHD and R Fever cause MAT regurge, then chronic stenosis
        
        FEVERS / RHD = Mitral regurge and VSD same
        --> holosystolic murmur
    - - Diastolic Murmurs
        
        think Diastolioc = morning = AM
        
        Aortic Regurgitation
        
        Mitral Stenosis
        
        note that BOTH diastolic murmurs MS and ARegurge START with a decrescendo
        
        go by the shape of the Letter
        --> A sideways = Decrescendo ONLY
        --> M has two humps = EXACT same M shape
        
        *Aortic Regurgitation
        
        Decrescendo Diastolic murmur
        
        "AR you gonna BLOW me with a BOBBING head??"
        
        Aortic stenosis is crescendo descredo big A
        
        Regurge is a sideward A = Decrescendo
        
        PathoPhys
        
        CLinical Caes
        
        1 more item...
        
        Wide Pulse pressure and heart pressures
        
        systolic increases
        --> due to regurge and higher ESV for the next pump
        
        diastolic decreases due to regurge of blood back into the heart quickly
        
        viscious cycle
        
        1 more item...
        
        Clinical Cases
        
        A regurge case
        
        Clinical Case
        
        Notes:
        
        note that
        
        Chronic Aortic Regurge
        
        very high blood volume return back into the LV after each stroke = up to 50%
        
        leads to dilated cardiomyopathy to compensate for the high blood volume
        
        this adaptation is able to compensate with a higher SV for a while
        
        but leads to LV HF eventually
        
        "AR you gonna BLOW me with a BOBBING head??"
        
        AR = Aortic Regurge
        
        BLOW = blowing murmur in AR
        
        Bobbing head = Aortic Regurge has bobbing head with heart beat = Musset's SIgn
        
        *Mitral Stenosis
        
        Openning Snap / loud S1 (MV closing)
        
        99% of MV stenosis are from RHD
        --> note they can appear 10 -20 years after initial Rheumatic Fever = chronic RHD
        --> mitral regurge is often the acute murmur
        
        Micro SOFT new OS = opening snap
        
        OS tells you the severity of MS
        --> faster the OS the worse the left atrium enlargement and worse MS
        
        Clinical Cases
        
        Clinical Case
        
        Notes:
        
        note that
        
        Clinical Case
        
        Tetralogy case
        
        Clinical Case
        
        Notes:
        
        note that
        
        Notes:
        
        "hihg frequency sound in Mitral Stenosis = OS"
        
        PathoPhys
        
        chronic RHD causes fibrous thickening of the MV and then fusion of the leaflets
        
        Clinical Cases
        
        1 more item...
    - - *Gallops = Added heart Sound s3 and s4
        
        S3 = right after S2
        --> volume overload during rapid atrial --> ventricle filling
        --> normal in kids, young people and pregnant women
        
        S4 = very end of diastole / before the S1 heart sound
        --> final atrial kick against a stiffened LV
        --> ALWAYS pathological where s3 can be normal
        
        Clinical S3 and s4 added sounds:
        
        always check for gallops = s3 and s4 after all valves
        
        postion patient = left decubitis position
        
        have them expire out all their air
        
        use bell of stethoscope at the apex
        --> 5 ICS MCL
        
        s3 Gallop / Added heart Sound
        
        S3 = right after S2
        --> volume overload during rapid atrial --> ventricle filling
        --> normal in kids, young people and pregnant women
        
        Clinical Cases
        
        Clinical Case
        
        2 more items...
        
        s4 Gallop / Added heart Sound
        
        S4 = very end of diastole / before the S1 heart sound
        --> final atrial kick against a stiffened LV
        --> ALWAYS pathological where s3 can be normal
        
        Clinical Cases
        
        Clinical Case
        
        Clinical Case
        
        Notes:
        
        note that
        
        Clinical Case
        
        Notes:
        
        note that
        
        Clinical Case
    - - Continuous Murmurs
        
        "Machine-like Murmur"
        
        *PDA = patent ductus arteriosis
        
        present at birth, but normally closes within 1-3 days of life
        
        think ROBOTS like PDA = public Displays of Affection rules!
        --> PDA has machine -like murmur
      - *Split S2 Heart sound
        
        S2 heart sound = A2 + P2
        
        think aorta has more pressure so closes first
        
        due to high venous return to right atrium and right side of heart (ASD + valsava / deep inspiration)
        - "ASD = ATRIAL SPLIT DEFECT"
        
        Common Causes of Split S2 heart sound
        
        intermittent split S2 = normal
        --> on inspiration = temporary split S2
        --> increase in thoracic pressure increases the venous return to the right side of the heart
        --> forces pulmonary valve to stay open longer
        --> temporary split S2
        
        fixed split S2 = pathological
        --> ASD = atrial septal defect
        
        Paradoxical Split S2
        
        left bundle branch block = LBBB
    - - *Manouvers with Murmurs
        
        Increasing Afterload for Murmurs
        
        2 ways = squatting and Handgrip
        
        HandGrip = increase afterload ONLY
        
        squatting = increases BOTH afterload and Preload to the heart
        --> classic improvement for Tetralogy of Fallot
        
        Hand Grip = Increase Afterload
        
        pushes everything back from the aorta --> ventricle
        
        increases
        --> Aortic regurge
        --> mitral valve regurge
        --> VSD
        
        from here determine by location (aorta vs. mitral)
        
        Handgrip case
        
        Notes:
        
        note that
        
        Clinical Case
        
        Effects of Preload on Aortic Stenosis vs HOCM
        
        *Valsalva Manouver
        
        decreases preload
        
        same as standing
        
        Notes:
        
        In valsalva you can see the changes in the aorta pressure in 3 separate humps
        --> the heart mirrors this
        
        first big hump = instant increase in intrathoracic pressure
        --> increase aorta pressure
        
        then lower PRELOAD = main effect
        --> large decrease in aorta pressure
        
        small hump = from HR increase
        
        small dip from letting go of pressure on aorta after vasalva done
        
        large hump = CO returning to normal as preload increases
        
        *Inspiration and Expiration Manouver
        
        RINspiration and LEXpiration
        
        RINspiration increase right sided murmurs
        -LEXpiration increases left sided murmurs
        
        Notes:
        
        RINspiration
        --> right sided murmurs increase
        
        inspiration decreases intrathoracic pressure
        --> venous return to right side increases
        --> since vena cava is large and pressure difference = higher flow
        
        the pulmonary veins are the opposite with low pressure since they have excess arteries and veins that will fill if needed
        --> as pressure decreases, this allows more blood to pool in the pulmonary system
        --> less return to the left side of the heart
        
        LEXpiration
        --> left sided murmurs increase
        
        Clinical Cases
        
        Clinical Case
        
        3 more items...
        
        *Squatting Manouver
        
        increases preload and afterload
        
        increased preload is most important though
        --> Preload = squatting and leg raise are almost the same
        
        "Squatting DOWN with 2 legs"
        --> Squatting major preload effect and minor afterload effect good for differentiating 2 key things
        --> normally increased preload = LV volume dilation = increases MOST murmurs
        
        "SQUATTING is EAZY for TOF MVP HOCM athletes"
        --> TOF MVP HOCM athletes are both QUIET on squatting
        --> Squatting = increase preload = LV dilation
        --> LV dilation helps HOCM by openning the outflow obstruction from the SEPTAL thichenning
        --> LV dilation helps MVP by pulling the loose chords tight
        --> in TOF mainly AFTERLOAD increase from squatting closes the Aortic valve and opens the stenotic pulmonary valve
        
        Summary of Heart Valve *Manouvers
        
        3 basic types of Manouvers
        --> preload, afterload and Breathing (RINspiration and LEXpiration)
        
        Preload = think of upper vs. lower body manouvers
        --> standing up vs. squatting down
        --> valsalva vs. leg raise
        
        INCREASED preload = LOWER body manouvers
        --> squatting down and LEG raise
        --> increases preload to BOTH right and left heart
        --> squatting minor effect = increases afterload to left heart
        
        DECREASED preload = UPPER body manouvers
        --> standing up and VALSALVA
        --> decreases preload to BOTH right and left heart
        
        Afterload = Simplest test = Hand grip manouver
        --> isolated muscles in hands contracting
        --> exercise increases afterload to LEFT heart
        Breathing in / out = think of RINspiration vs LEXpiration
        
        RINspiration = RINspiration increases RIGHT sided murmors
        
        LEXpiration = LEXpiration increases LEFT sided murmors
        --> think of LEX luther from Superman
- - - - What to look for
        1 - look at the aorta line max and min to see systolic and diastolic pressures ~ 120 and 80
        --> If not, wide pulse pressure = aortic regurge
        2 - look for dichrotic notch = when the aortic valve closes
        --> if not present then aortic regurge
        3 - look to see LV and aorta match during systole
        4 - look at pressures for left atrium and shape opposite to aorta/ventricle
        --> if both raising at same time = mitral regurge