#38 – Cardiac Murmurs



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Aortic Stenosis

 

Causes

  • Congenitally abnormal valve (bicuspid)
  • Calcific disease –> most common in US
  • Rheumatic valve disease –> most common world wide

Signs and Symptoms

  • Dyspnea on exertion
  • Exertional dizziness or syncope
  • Angina

Description

  • High-pitched, crescendo-decrescendo (diamond shaped), midsystolic murmur
  • Soft S2
  • S4 may be present

Best Auscultation Position

  • Right 2nd intercostal space

Special Notes

  • Radiate to carotid arteries

Aortic Regurgitation

 

Causes

  • Aortic root dilation
  • Congenital bicuspid valve
  • Calcific disease
  • Rheumatic heart disease –> most common world wide

Signs and Symptoms

  • Exertional angina and yspnea
  • Symptoms of heart failure
    • PND, orthopnea, pulmonary edema, lower extremity edema
  • Laterally and inferiorly displaced PMI with a thrill

Description

  • Soft, high-pitched, early diastolic, decrescendo murmur
  • Soft S1 with soft/absent A2
  • S3 may be present

Best auscultation position

  • Left 3rd intercostal space near sternal border (Erb’s point)

Special Notes

  • Accentuated by patient sitting up and leaning forward at end expiration

Mitral Stenosis

 

Causes

  • Rheumatic heart disease is most common causes
  • Mitral annular calcification
  • Radiation associated-valve disease (Hodgkin’s lymphoma)

Signs and Symptoms

  • Exertional dyspnea
  • Decreased exercise tolerance
  • Hemoptysis (increased pulmonary pressure)
  • Angina
  • Fatigue
  • Atrial fibrillation (elevated left atrial pressure)
  • Hoarseness

Description

  • Opening snap with low-pitched, diastolic murmur
  • Decrescendo after S2
  • Late, diastolic, crescendo before S1
  • Loud S1

Best auscultation position

  • Cardiac apex at left 5th intercostal space, midclavicular line

Special Notes

  • Patient in left lateral decubitus in held expiration
  • Using the bell

Mitral Regurgitation

 

Causes

  • Primary
    • Degenerative mitral valve disease à most common in US
      • Mitral valve prolapse
    • Rheumatic heart disease
    • Infective endocarditis
    • Trauma
    • Congenital valve cleft
    • Mitral annular calcification
  • Secondary
    • Coronary artery disease (regional wall motion abnormality)
    • Dilated cardiomyopathy
    • Hypertrophic cardiomyopathy

Signs and Symptoms

  • Exertional dyspnea
  • Fatigue
  • Atrial fibrillation
  • Heart failure

Description

  • High-pitched “blowing”, holosystolic murmur
  • Diminished S1

Best auscultation position

  • Cardiac apex at left 5th intercostal space, midclavicular line

Special Notes

  • Radiates to axilla
  • No variability in respiration
  • Decreases in intensity with valsalva

Mitral Valve Prolapse

 

Causes

  • Primary
    • Sporadic (myxomatous degeneration)]\
    • Familial (autosomal dominant with incomplete penetration)
      • 30-50% in 1st degree relatives
  • Secondary
    • Connective tissue disorders
    • 23CVInfective endocarditis
    • Coronary artery disease

Signs and Symptoms

  • Palpitations
  • Dyspnea
  • Exercise intolerance
  • Dizziness or syncope
  • Panic and anxiety disorders
  • Numbness or tinging

Description

  • Midsystolic click followed by a uniform, high-pitched, late systolic murmur

Best auscultation position

  • Cardiac apex at left 5th intercostal space, midclavicular line

Special Notes

  • Responds to dynamic auscultation
    • Increased in sudden standing
    • Decreased in sudden squatting

Tricupsid Stenosis

 

Causes

  • Rheumatic heart disease
  • Atrial myxoma
  • Carcinoid syndrome

Signs and Symptoms

  • Abdominal discomfort
    • Hepatic congestion and heptomegaly
  • Fluttering sensation in neck caused by jugular venous pulse
  • JVD, ascites, peripheral edema

Description

  • Soft, high-pitched, mid-diastolic

Best auscultation position

  • 4th intercostal space on the sternal border

Special Notes

  • Increased during inspiration, squatting, or leg raise

Tricuspid Regurgitation

 

Causes

  • Functional
    • Dilation of right atrium and ventricle with dilation of tricuspid annular leaflet
      • Pulmonary hypertension, left-sided heart failure, left-to-right shunt
  • Valvular
    • Valve damage from pacemaker or ICD
    • Infective endocarditis
    • Rheumatic heart disease
    • Ischemic heart disease

Signs and Symptoms

  • Majority are symptomatic
  • Right-sided heart failure
    • Hepatomegaly, hepatic congestion, ascites, hepatic venous hum, JVD, edema

Description

  • High-pitched, holosystolic murmur

Best auscultation position

  • 4th intercostal space on the sternal border

Special Notes

  • Radiates to right sternal border
  • Increases with inspiration, leg raises, or squatting

Pulmonic Stenosis

 

Causes

  • Congenital (10% of children with congenital heart disease)
    • Tetralogy of Fallot
    • Noonan Syndrome
  • Bicuspid valves
  • Calcification

Signs and Symptoms

  • Exertional dyspnea
  • Right heart failure

Description

  • Midsystolic, high-pitched, crescendo-decrescendo
  • Pulmonary ejection click
  • Extends through the A2
  • Splitting of S2

Best auscultation position

  • Left 2nd intercostal space

Special Notes

  • Increased during inspiration

Pulmonic Regurgitation

 

Causes

  • Primary
    • Iatrogenic, infectious, rheumatic, congenital
  • Secondary
    • Pulmonary artery hypertension and/or dilation
  • Physiologic (incidental)

Signs and Symptoms

  • Asymptomatic until right ventricular dysfunction occurs
    • Exertional dyspnea, fatigue
    • Tachyarrythmias

Description

  • Soft, high-pitched, early diastolic decrescendo
  • Graham-Steele murmur (pulmonary HTN)
    • High-pitched, blowing with accentuated P2

Best auscultation position

  • Left 2nd intercostal space

Special Notes

  • Increased with inspiration

S3 (ventricular gallop)

 

Causes

  • Large amount of blood hitting a very compliant left ventricle
    • Systolic heart failure

Description

  • Low-pitched, early diastolic sound
  • Occurs after S2

Best auscultation position

  • Cardiac apex at left 5th intercostal space, midclavicular line

Special Notes

  • Present with bell and absent with diaphragm

S4 (atrial gallop)

 

Causes

  • Blood striking a non-compliant left ventricle
    • Diastolic heart failure, LVH

Description

  • Low-pitched, late-diastolic murmur

Best auscultation position

  • Cardiac apex at left 5th intercostal space, midclavicular line

Special Notes

  • Present with bell and absent with diaphragm



Cottage Physician

 



References

  1. Eveborn GW, Schirmer H, Heggelund G, Lunde P, Rasmussen K. The evolving epidemiology of valvular aortic stenosis. the Tromsø study. Heart (British Cardiac Society). 2013; 99(6):396-400. [pubmed]
  2. Enriquez-Sarano M, Tajik AJ. Clinical practice. Aortic regurgitation. NEJM. 2004; 351(15):1539-46. [pubmed]
  3. Horstkotte D, Niehues R, Strauer BE. Pathomorphological aspects, aetiology and natural history of acquired mitral valve stenosis. European heart journal. 1991; 12 Suppl B:55-60. [pubmed]
  4. Hull MC, Morris CG, Pepine CJ, Mendenhall NP. Valvular dysfunction and carotid, subclavian, and coronary artery disease in survivors of hodgkin lymphoma treated with radiation therapy. JAMA. 2003; 290(21):2831-7. [pubmed]
  5. Chandrashekhar Y, Westaby S, Narula J. Mitral stenosis. Lancet (London, England). 2009; 374(9697):1271-83. [pubmed]
  6. Freed LA, Benjamin EJ, Levy D. Mitral valve prolapse in the general population: the benign nature of echocardiographic features in the Framingham Heart Study. Journal of the American College of Cardiology. 2002; 40(7):1298-304. [pubmed]
  7. Strahan NV, Murphy EA, Fortuin NJ, Come PC, Humphries JO. Inheritance of the mitral valve prolapse syndrome. Discussion of a three-dimensional penetrance model. The American journal of medicine. 1983; 74(6):967-72. [pubmed]
  8. Sagie A, Schwammenthal E, Padial LR, Vazquez de Prada JA, Weyman AE, Levine RA. Determinants of functional tricuspid regurgitation in incomplete tricuspid valve closure: Doppler color flow study of 109 patients. Journal of the American College of Cardiology. 1994; 24(2):446-53. [pubmed]
  9. Snellen HA, Hartman H, Buis-Liem TN, Kole EH, Rohmer J. Pulmonic stenosis. Circulation. 1968; 38(1 Suppl):93-101. [pubmed]
  10. Nishimura RA, Otto CM, Bonow RO. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology. 2014; 63(22):e57-185. [pubmed]
  11. Ozawa Y, Smith D, Craige E. Origin of the third heart sound. II. Studies in human subjects. Circulation. 1983; 67(2):399-404. [pubmed]
  12. Abrams J. Current concepts of the genesis of heart sounds. II. Third and fourth sounds. JAMA. 1978; 239(19):2029-30. [pubmed]
  13. Learn The Heart. https://www.healio.com/cardiology/learn-the-heart

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