Download Murmurs: Need to look for - Ipswich-Year2-Med-PBL-Gp-2

Anatomy and physiology of heart valves and
supporting structures, focus on heart
murmurs
Heart sounds
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Sounds are due to the vibrations created within the ventricular/arterial walls during valve
closure
Turbulent blood flow produces murmurs  this turbulent flow causes vibrations which can be
heard (laminar flow cannot be heard)
S1 is due to closure of both the tricuspid and mitral valves
S2 is due to closure of both the aortic and pulmonary valves
S3 is due to abrupt cessation of filling of the ventricles
S4 is related to atrial filling and is due to blood being forced into a stiff/hypertrophic ventricle
Stenotic/insufficient valves
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stenotic valve= stiff, narrowed, doesn’t fully open
o Requires high velocity to force the blood through the closure  “whistling” turbulence
Insuffient/incompetent valve = cannot close properly
o Usually the valve edges are scarred and don’t fit together properly
o “swishing”/”gurgling” murmur as there is mixing of blood flowing in different directions
o Both usually caused by rheumatic fever
Murmurs: Need to look for
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Timing: systolic Vs diastolic  ie. AV Vs semilunar valves
Pitch/sound/quality: whistling Vs swishing  ie. stenosis Vs regurgitation
Location: aortic Vs pulmonary Vs tricuspid Vs mitral areas
Radiation  this is due to the direction of turbulent flow and is only detectable when there is a
high-velocity flow of blood
Murmur
Aortic
stenosis
Mitral valve
prolapsed
Mitral
regurgitation
Pulmonary
stenosis
Timing/sound/other features
Mid-systolic ejection murmur; in late stages may
have a S4 and/or quiet/missing S2
Normal S1; briefly quiet systole; mid-systolic click
(valve prolapsed); sometimes a brief crescendodecrescendo murmur
Blowing, holosystolic, can have an S3 (due to atrial
volume overload); S1 may be quieter; S2 can be
markedly split
Crescendo-decrescendo shape; significant S2
splitting
Location/radiation
Aortic area, radiation into neck
Murmur usually at apex
At apex, radiates into axilla
Pulmonic area, radiates into
neck/back
Ventricular
septal defect
Atrial septal
defect
Aortic
regurgitation
Mitral
stenosis
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Holosystolic murmur, split S2
Tricuspid area, radiates to right
lower sternal border
Mid-systolic flow murmur, fixed split S2
Pulmonic area, may radiate into
back
Early mid-systolic flow murmur
Right upper sterna border,
radiates into neck
Blowing, decrescendo diastolic sound
3rd left intercostals space,
radiates along left sterna border
Nearly holodiastolic, pre-systolic accentuation, low- Apex, little radiation
pitched, decrescendo, rumbling, has an opening
‘snap’
AS: early murmur suggests early stage of disease; late murmur suggests late stage of disease
Flow murmurs are due to high flow through a normal valve  eg. in pregnancy or anaemia
www.wilkes.med.ucla.edu has heaps of good audio clips to listen to the murmurs
Ejection systolic murmur
(AS, PS, aortic or pulmonary flow murmurs)
Pansystolic murmur
(MR, TR, VSD)
Late systolic murmur
(MV prolapsed)
Early diastolic murmur
(AR, PR)
Mid-diastolic murmur
(MS, RS, mitral or tricuspid flow murmurs)
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