Download Cardiac Cycle: End Systole

Do You Hear What I Hear Here?
A Primary Care Approach to Murmurs, and
Heart Sounds and Clicks, Oh My.
Benjamin Hoffman MD, FAAP
Assistant Professor of Pediatrics
University of New Mexico
OBJECTIVES
Objectives
• By the end of this talk, you should be able to:
• Describe When and Where Blood Flows in the
Heart
• Discuss Basics of Cardiac Auscultation
• Discuss Different Types of Murmurs
– Pathologic
– Innocent
• Make Appropriate Referrals
What is a Murmur
• The Sound of
Turbulent Flow
– Whitewater!
• Estimated 75-100% of
children throughout
their lifetime
• Show Me the Blood
Flow!
Cardiac Cycle: End Systole
Semi-lunar valves
Closed
Vent. Pressure=
Great Artery Pressure
No Blood Flow
Cardiac Cycle:Early Diastole
Vent. Relaxation=
Isovolumetric Relaxation
Closure of Semilunar Valves=
S2
Atrial Filling
(Silent)
P2
A2
Cardiac Cycle: Diastole
Increased Atrial Pressure
Decreased Vent. Pressure
Pa>Pv: AV Valves Open,
Rapid Passive Filling (80%)
Cardiac Cycle: Atrial Systole
Atrial Systole
20% of Atrial Ejection
Cardiac Cycle:Systole
Ventricular Systole
Rapid Increase Pv
Pv>Pa: AV Valve Closure
S1
THIS IS THE KEY
ISOVOLUMETRIC
Contraction
Period After S1
NO BLOOD FLOW
Cardiac Cycle: Systole
Pv increases,
SL valves open
Ejection
The Challenge
• To Distinguish the
Good, the Bad and the
Ugly
– What do we need to
know?
– When do we Refer?
Characterizing Murmurs
• Where
– Is it loudest, Does it Radiate
• When
– Systolic, Diastolic
• How
– Pitch, Quality, Shape
Levine Classification
Levine Classification
Where Do You Listen?
Heart Sounds
• S1:
– Occurs at the onset of
systole
• Associated with A/V
valve closure
• Intensity of directly
related to peak rate of
rise of LV pressure
Ode to a Second Heart Sound
• S2:
– The ability to hear this
is crucial
– Associated with closure of
semilunar valves
– Normally split with
respiration, A2-P2
P2
A2
Splitting of S2
Expiration
Inspiration
Ode to a Second Heart Sound
• Fixed: ASD
• Loud: Increased Pulmonary Pressures
• Single:
– Truncus Arteriosis,
– Transposition (Pulm. Valve Posterior)
Miscellaneous Sounds
•S3: low frequency sound at
end of rapid filling
•Ejection clicks:
–sudden limitation to filling
–bileaflet semilunar
valve
–normal or abnormal depending
on context
–dilated Ao or PA
•S4: atrial kick into a noncompliant ventricle
(abnormal)
–Mid-systolic click
–MVP
•Opening Snap
–MS
Auscultation Helpers
• Inspiration
– Increased venous return to RV> increased right heart murmur
• Expiration
– Increased pulmonary blood
flow and return to LV->
increased left heart murmur
• Clicks are best
appreciated sitting
Auscultation Helpers
• Evaluation in different positions
– Supine: End-diast. volume is increased-> increased
stroke-volume
• Any outflow murmur that is dependent the amount
of flow will be louder supine
– EXCEPTION: Hypertrophic cardiomyopathy
» When sitting, intracardiac volume is decreased->
increased outflow obstruction -> increased murmur.
Auscultation Helpers
• Valsalva:
– Increased intrathoracic pressure->decreased venous return->
decreased end-diastolic volume.
• Hypertrophic cardiomyopathy murmur increased
• Mitral regurg. is increased, click of mitral valve prolapse is increased.
– Release of Valsalva
• increased blood flow to right heart-> accentuation of right-sided
murmurs.
• On 2nd or 3rd beat, increased blood flow to left heart, accentuating
murmurs there.
Murmurs
Only 2 Types
Systolic
Innocent
Diastolic
Pathologic
Diastolic Murmurs
LATE
Early Diastolic
Late Diastolic
Semi-Lunar Valves
Regurg
A-V Valves
Stenosis
EARLY
P2
A2
Diastolic Murmurs
• Low Pressure, Low
Flow
• Hard to Hear!!!
• REFER!!!!
Systolic Murmurs
Only 2 Types
Systolic
Innocent
Pathologic
Systolic
Ejection
Ejection S1 Coincident
(Holosystolic)
Innocent
Pathologic
Systolic Murmurs: Pathologic
• S1 Coincident
• Regurgitation at AV
valves
• Occurs with, or
Obscures S1
• REFER!!!!!!!!
S1
Ejection Murmurs
• Remember
Isovolumetric
Contraction
– S1, then a break before
opening of SL valves.
• Occurs Mid-Late
Systole
– Can Clearly Differentiate
S1
– Crescendo, Decrescendo
S1
S1
Systolic Murmurs: Pathologic
• Ejection
• Occurs at the Outflow Tract
– Subvalvular
• IHSS/HOCM
– Valvular
• AS, PS
– Opening Snap
– Supravalvular
• Coarctation
– Pulses, 4 Ext BP
HCM: A Special Case
• Unregulated
Proliferation of Septal
Wall Muscle
• Mobile Obstruction
• Systolic Ejection
Murmur Loudest
When End-Diastolic
Volume Smallest
What about VSD’s, Einstein?
• Most Common
Congenital Lesion
– 25% CHD
– 90-95% Resolve by 1st
Birthday
• Remember: V=IR
– I=V/R
• Smaller= Louder, and
Later
• S1 Coincident, or
Ejection
S1
S1
And ASD’s??
• “Fixed Split” S2
– Increased End Diastolic
Volume Right Ventricle
• Pulmonic Flow
Murmur
– Low Pitched, Rumble-y
• Rabbit Ears on EKG
– RBBB
A2
Systolic Murmurs: Innocent
• Mumurs Not Associated with
Anatomic or Physiologic
Abnormalities
• 50-100% of Children
• Early Systolic Ejection, Short
Duration, Grade I-III, DO Not
Radiate
Still’s Murmur
• Age over 2 years
• Gr. I-III, Short, MidSystolic
• Apex, LLSB
• Why?
– Narrower than Ventricle
– More Acute Angle
– “Bottleneck around a
Corner!”
Still’s Murmur
• Quality:
– Musical, Harmonic,
Vibratory
– Low Frequency
• Bell>Diaphragm
– Loudest Supine
– Fluid Flowing over a
String?
Pulmonic Flow Murmur
• Any Age Group
• Gr. I-III, Blowing,
Mid-Systolic
• Diaphragm>Bell
• LUSB
• May Radiate to Back
• Loudest Supine
Peripheral Pulmonic Stenosis
• Newborns (2-6 Months)
– Especially Premies
• Gr. I-II, “breathy”, high
pitched
• As Loud, or Louder, in
Axillae
• Small Caliber, Acute
Branching of Branch PA’s
Other Innocent Murmurs
• Venous Hum
– Present Only Sitting
– Disappears Supine
– Clavicle/Neck
• Carotid Bruit
• Mammary Souffle
Questions?
So, What DO We Do?
• Listen Carefully
• Use Ancillary Tests to Help
– EKG, CXR, Oximetry, 4 Ext. BP’s
• Refer:
–
–
–
–
–
All Grade IV-VI
All Diastolic
All S1 Coincident Systolic
Cyanosis, Decreased Pulses or LE BP’s
Poor Feeding, Sweating, Poor Weight Gain
Murmurs and Appy’s???
• No Shame in
Referring an Innocent
Murmur!!!
• Phone/Fax your
Friendly Cardiologist