IVMS ICM-Heart Murmurs
IVMS ICM-Heart Murmurs
IVMS ICM-Heart Murmurs
Website: http://ivmsicm.blogspot.com/
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Heart Murmurs
Marc Imhotep Cray, M.D.
Companion Online Folder:
IVMS-Physical Diagnosis Notes and Reference Resources
12 p.
IVMS Basic Medical Science of Valvular Heart Disease Also see: Cardiac Auscultation 101: A Basic Science Approach to Diagnosing Heart Murmurs, Christopher Hanifin, PA-C
Outline
I. Basic Pathophysiology II. Describing murmurs III. Systolic murmurs IV. Diastolic murmurs V. Continuous murmurs VI. Summary
Basic Pathophysiology
Ventricular Pressure-Volume Loop Changes in Valve Disease Cardiac valve disease significantly alters ventricular pressure and volume relationships during the cardiac cycle. A convenient way to analyze cardiac pressure and volume changes is by using ventricular pressure-volume loops.The links below will illustrate the pressurevolume changes that occur with the following valve defects: Mitral stenosis Aortic stenosis Mitral regurgitation Aortic regurgitation
Systolic
Diastolic
Aortic stenosis
Mitral stenosis
ii. Variation with position of the patient iii. Variation with special maneuvers
Valsalva/Standing => Murmurs decrease in length and intensity EXCEPT: Hypertrophic cardiomyopathy and Mitral valve prolapse
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Systolic Murmurs
Derived from increased turbulence associated with:
1. Increased flow across normal SL valve or into a dilated great vessel 2. Flow across an abnormal SL valve or narrowed ventricular outflow tract - e.g. aortic stenosis
3. Flow across an incompetent AV valve - e.g. mitral regurg. 4. Flow across the interventricular septum
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decrescendo murmur best heard at apical impulse Caused by: i. Papillary muscle rupture ii. Infective endocarditis iii. Rupture of the chordae tendineae iv. Blunt chest wall trauma
2. Congenital, small muscular septal defect 3. Tricuspid regurg. with normal PA pressures
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1. Innocent
common in children and young adults
2. Physiologic
can be detected in hyperdynamic states e.g. anemia, pregnancy, fever, and hyperthyroidism
3. Pathologic
are secondary to structural CV abnormalities e.g. Aortic stenosis, Hypertrophic cardiomyopathy, Pulmonic stenosis
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Aortic stenosis
Loudest in aortic area; radiates along the carotid arteries Intensity varies directly with CO A2 decreases as the stenosis worsens Other conditions which may mimic the murmur of aortic stenosis w/o obstructing flow:
1. 2. 3. 4.
Aortic sclerosis Bicuspid aortic valve Dilated aorta Increased flow across the valve during systole
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Hypertrophic cardiomyopathy
Loudest b/t left sternal edge and apex; Grade 2-3/6 Does NOT radiate into neck; carotid upstrokes are brisk and may be bifid Intensity increases w/ maneuvers that decrease LV volume
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Loudest at the left ventricular apex Radiation reflects the direction of the regurgitant jet i. To the base of the heart = anterosuperior jet (flail posterior leaflet) ii. To the axilla and back = posterior jet (flail anterior leaflet Also usually associated with a systolic thrill, a soft S3, and a short diastolic rumbling (best heard in left lateral decubitus
2. Tricuspid valve regurgitation 3. Ventricular septal defect
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Diastolic Murmurs
Almost always indicate heart disease Two basic types: 1. Early decrescendo diastolic murmurs
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Aortic Regurgitation
Best heard in the 2nd ICS at the left sternal edge High pitched, decrescendo Blowing quality => may be mistaken for breath sounds Radiation: i. Left sternal border = assoc. with primary valvular pathology; ii. Right sternal edge = assoc. w/ primary aortic root pathology Other associated murmurs: i. Midsystolic murmur ii. Austin Flint murmur
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Mitral Stenosis
Two components: 1. Middiastolic - during rapid ventricular filling 2. Presystolic - during atrial contraction; therefore, it disappears if atrial fibrillation develops Is low-pitched and best heard over the apex (w/ the bell) Little or no radiation Murmur begins after an Opening Snap; S1 is accentuated
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Continuous Murmurs
Begin in systole, peak near s2, and continue into all or part of diastole. 1. Cervical venous hum
Represents augmented arterial flow through engorged breasts Becomes audible during late 3rd trimester and lactation
3. Patent Ductus Arteriosus
II. Diastolic Murmurs: 1. Aortic regurgitation - early diastole 2. Mitral stenosis - mid to late diastole
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Summary
A. Presystolic murmur Mitral/Tricuspid stenosis B. C.
D. E.
F. G.
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