Download Murmurs - stjpap 2011

Murmurs
Mitral Stenosis
Mitral Regurgitation
Mitral Valve Prolapse
Aortic Stenosis
Localized, mid-dilated, low pitch
“Opening snap w/ apical diastolic rumble”
IR Atrial fibrillation, decrescendo
Dyspnea, orthopnea,
paroxysmal nocturnal dyspnea
Clubbing, Rales, Elevated JVD
“Holostolic” soft S1
LV hypertrophy
IR Atrial fibrillation
“Floppy” (free flap)
Mid-systolic click
Asymptomatic (mild)
Dyspnea, orthopnea, PND
Pulmonary edema & rales
Asymptomatic OR nonspecific dyspnea or fatigue
* lean individuals
Valvular narrowing w/ resistant LV outflow
Diminished carotid pulses; soft split S2
Mid-systolic ejection R2ICS w/ radiation to the neck
Crescendo-decrescendo; “systolic thrill”
MCC: calcification of valves
Aortic Regurgitation
Hyperactive, enlarged LV
“Blowing”; decrescendo
L2ICS; diastolic
infective endocarditis/ aortic dissection- surgery
Triad: angina pectoris, syncope, heart failure
marfan’s syndrome; HTN
Pulmonic Stenosis
Lesion assoc. w/ obstruction to RV outflow
Audible in LU sternal border to the back/ post. lung fields
Systolic ejection: crescendo-decrescendo; “systolic thrill”
Hx of murmur since birth
Acyanosis, Dyspnea, Dizziness
[10% - CHF]
High pressure pulmn  loud, diastolic
Low pressure pulmn  soft or none
Graham-Steel: high pitched decrescendo, diastolic at 2ICS &
mid-sternal border
Pulmonary HTN
Tolerated well
Pulmonic Regurgitation
Tricuspid Regurgitation
Holostolic, blowing, high pitched
Inc. w/ inspiration
Seen w/ RV failure & pulmn HTN
Idiopathic Hypertrophic
Subaortic Stenosis
LV outflow narrowed during systole; loud S4; triple apical
impulse; worsened via cardiac contractility or  LV filling
(Valsalva manuever)
Syncope, Arrhythmias
Chest Pain, Dyspnea
incidence of sudden death
Blood Flow  Laminar flow is the normal blood flow  turbulent flow occurs when laminar flow is disrupted
Atria Systole- atria contract Ventricle Systole- ventricles contract Diastole- heart fills with blood after systole
Heart Valves  Thin leaflets composed of tough, flexible endothelium-covered fibrous tissue, attached to fibrous valve rings
Murmur Description  Location; intensity; duration; pitch; quality; timing
S1  closure of mitral valve [lub]
S2  closure of aortic valve [dub]
S3  ventricular diastolic gallop [CHF]
S4  decreased ventricular compliance [MI]
Grading of MURMURS:
1. very faint, “tuned in”
2. quiet but heard after placing stethoscope of chest
3. moderately loud
4. loud w/ palpable thrill
5. very loud, sthethoscope partially off the chest
6. very loud, sthethoscope completely off the chest
R. Sided murmurs: intensity w/ inspiration
L. Sided murmurs: intensity w/ inspiration
Diagnostics
Chest X-Ray
Electrocardiogram (EKG)
Heart size, primary pulmonary disease, aortic abnormalities
Hypertrophy of chambers, aortic stenosis (LV), tricuspid stenosis (RA), aortic regurgitation
Echocardiogram
Valve morphology, LV mass/ function, atrial/ ventricular chamber size, BEST for stenotic
Transesophageal Echocardiography Valvular vegetations, thrombi
Doppler Ultrasound
Pulsed, color flow, tissue
Stress Echocardiography
Evaluate gradient changes durin and after exercise, NOT for aortic stenosis
Cardiac Catheterization
R.heart: elevated pressure due to pulm and cardiac disease; CX: pneumothorax, PE infxn
L.heart: evaluate pressure and severity of CAD; helpful for regurgitant valves
Treatment
Drugs- Diuretics (relieve fluid build up in lungs), ACE-I (reduce workload for the heart), Digoxin (stabilize rhythm/ pumping),
B-Blockers (dec. palpitations), Anticoagulants (prolong clotting). Vasodilators (lessen work load)
Surgery- when drugs cannot control obstruction; valvuloplasty, percutaneous ballon valvotomy, repair/ replacement
Antibiotic Prophylaxis- *pts w/ prolapse AND regurgitant valves [clicks and murmurs] NOT for mitral valve prolapse