Cardiology Murmurs

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  2. What is my acronym for Eric Strong's 8 qualities of a murmur ?
    To Like Richmond; you Should Put Intense Questioning Aside
  3. What does this acronym stand for ?
    Timing; Location; Radiation; Shape; Pitch; Intensity; Quality; Manouvers
  4. What does timing refer to ?
    Where in the cycle; systolic; diastolic; continuous
  5. What are the main systolic murmurs ?
    AS; MR; (PS + TR); VSD; HOCM; Flow murmurs
  6. What are the main diastolic murmurs ?
    AR; MS; (+PR and TS)
  7. What can cause a continuous murmur ? (2)
    PDA; AS+AR
  8. What determines the location of a murmur ?
    Where it is most easily heard
  9. What can be the problem with describing the location of a murmur ?
    Aortic murmur can be heard everywhere
  10. "What does ""radiation"" refer to ?"
    Where the murmur is heard despite not being directly over the heart
  11. Give three examples of radiation !
    AS - Carotids; TR - RSE; MR - Axilla
  12. What are the three basic murmur shapes ? Where do they occur ?
    Cresecendo decrescendo (systolic); Pan (systolic); Descendo (diastolic)
  13. How are AR; AS; MR and MS shapes described
    AR- Descescendo diastolic; AS - Crescendo Decrescendo; MR - pan systolic; MS - pan systolic
  14. What are the 3 types of pitch ? Examples ;
    High - high pressure gradient (VSD); Low - low pressure high volume (MS); Harsh - high pressure high volume (AS)
  15. What are the 6 grades of murmur intensity ?
  16. Describe the quality of AR; AS; MR and MS !
    AR - blowing; AS - harsh; MR - blowing; MS - rumbling
  17. What are the major manouvers ? (4)
    Clenching fist; valsalva; squatting; inspiration/expiration
  18. What does fist clinching do ? What does it bring out ? What does it bring out ?
    Increases afterload; MR increased intensity; AS decreased intensity; Brings out AR
  19. What does squatting or supine positioning do ? What does it distinguish ?
    Increases venous return; AS increased intensity; HOCM decreases intensity; Can bring out AR
  20. What does the valsalva do ? What does it distinguish ?
    Decreases venous return; AS decreases in intensity; HOCM increases intensity
  21. What happens with inspiration ?
    Inspirataion increases RV preload; decreases LV preload; increases right sided murmurs
  22. What happens with expiration ?
    Expirataion decreases RV preload; increases LV preload; increases left sided murmurs
  24. Why is aortic stenosis described at an ejection systolic murmur ?
    Pressure gradient only in systole; maximal mid systole.
  25. Where does the ESM in AS radiate?
    Radiates to the carotids; ESM = Ejection systolic murmur
  26. How is an ESM described
    Crescendo-descrescendo mrmur
  27. What can be expected to happen to the heart sounds in AS ?
    Reverse spit of S2 (split on inspiration); S3 and S4
  28. What rhythm is usually associated with aortic stenosis ?
    Sinus (AF unusual)
  29. What happens to BP in severe AS ? (High/Low)
    Usually low (unusual for it to be high)
  30. How is the pulse described in aortic stenois ? (3)
    Small volume; plateau; slow up-rise
  31. What is radiation of aortic stenosis to the apex called ?
    Gallavardin phenomenon
  32. How is the apex bead described in aortic stenosis ?
    Presure loaded; heaving
  33. Where are thrills felt in aortic stenosis ?
    Base of the heart; aortic valve
  34. What are the main signs of severity aortic stenosis ?
    Plateau pulse; aortic thrill; length and lateness of the peak; S4; reverse spit S2; LVF
  35. How loud is a severe aortic stenosis ?
    Usually 3-4/6 (unless low stroke volume)
  36. What systemic features indicate severit of aortic stenosis ?
    LVF and basal crackles
  37. In mild aortic stenosis gradient is ___ mmHg or Area ___ cm2
    <25 mmHg; >1.5 cm
  38. In moderate aortic stenosis gradient is ___ mmHg or Area ___ cm2
    25-40 mmHg; 1.5-1.0 cm
  39. In severe aortic stenosis gradient is ___ mmHg or Area ___ cm2
    >40 mmHg; <1.0 cm
  40. In clinical aortic stenosis gradient is ___ mmHg or Area ___ cm2
    >80 mmHg; <0.5cm
  41. What is the normal area of the aortic valve ?
    3-4 cm
  42. What are the three most common underlying pathologies of aortic stenosis ?
    Degenerative; Bisuspid aortic valve and rheumatic valve
  43. What are the three main symptoms of aortic stenosis (Arnold Schwartzenegger Disease) ?
    Angina; syncope and dyspnoea
  44. What are the relevant frequencies of angina; syncope and dyspnoea in AS presentation ?
    Angina - 35%; Syncope - 15%; Dyspnoea - 50%
  45. Uncorrected; what is the mortality of angina; syncope and dyspnoea ?
    Half dead: Angina - 5 yrs; Syncope - 3 years; Dyspnoea - 2 years
  46. In aortic stenosis; what happens to survival post AVR ?
    Approaches normal
  47. What is required for surgery in AS ?
    Severe AS; with/without symptoms
  48. What are the surgical options ?
    Valvotomy; TAVI
  49. What is the surgical mortality with AS ?
    4%; Frank CCF 15-20%
  51. What can cause functional mitral regurgitation ?
    Left ventricle dilatation
  52. What are the four most common causes of mitral regurgitation ?
    Mitral valve prolapse; ischaemia; rheumatic heart disease; endocarditis
  53. Which rhythm is common in mitral regurgitation ?
    Atrial fibrillation
  54. What happens to the apex beat in mitral regurgitation ?
    Displaced dyskinetic / diffues
  55. What happens to the heart sounds in mitral regurgitation ?
    S1 diminished (MV leaflets fail to close); S2 split; S3 and S4 (if in sinus)
  56. How is the murmur in mitral regurgitation described ?
    Apical pan-systolic murmur that radiates to the axilla
  57. Where does the murmur occur in mitral regurgitation relative to S1 and S2 ?
    Immediately after S1 up to and may obscure S2
  58. Where is the thrill in mitral regurgitation ?
    Apex (if present)
  59. What associated abnormalities are common in mitral regurgitation ?
    TR; MS and Pulmonary HTN
  60. What features of the heart sounds indicate severity in mitral regurgitation ? (3)
    Soft S1; split S2; S3
  61. What features of the left ventricle indicate severity of mitral regurgitation ?
    LV dilatation; LVF
  62. What rumble is a sign of severity of mitral regurgitation ?
    Early diastolic rumble
  63. What right heart failure features indicate severe mitral regurgitation ?
    Pulmonary hypertension
  64. What about pulse volume indicates severe mitral regurgitiation ?
    Small pulse volume
  65. What are some indications for surgery in chronic mitral regurgitation ?
    Acute MR; NYHA III/IV symptoms; LV dysfunction but EF > 30%
  67. HOCM is an ESM; louder on _____; softer with _____ _____ !
    HOCM is an ESM; louder on valsalva; softer with hand grip !
  68. If the aortic area is quiet; when should we think of HOCM ?
    ESM at lower LSE
  69. What do we expect on auscultation with HOCM ?
    Late ESM maximum at LSE; S4; Pansystolic murmur of mitral regurgitation at apex (systolic anterior motion)
  70. What is the characteristic of the apex beat in HOCM ?
    Double impulse (pre-systolic ventricular dilatation post atrial contraction)
  71. In HOCM JVP may have a prominent ___ wave ?
    Prominent a wave
  72. The pulse in HOCM is _____ !
  73. What causes acquired HOCM ?
    Long standing HTN
  74. What are some genetic causes of HOCM ?
    AD with variable penetrance
  75. HOCM is always obstructive / non-obstructive ?
    May be obstructive or non-obstructive
  77. What is the male:female ratio for aortic regurgitation ?
    Male:female = 3:1
  78. What murmur does aortic regurgitation present with ?
    Decrescendo diastolic murmur
  79. What are the two main physiological causes of aortic regurgitation ?
    Valve disease; aortic root incompetence
  80. Which valvular diseases can cause aortic regurgitation ? (3)
    Rheumatic (no just AR); congenital (in association with VSD); Endocarditis
  81. Which aortic root diseases can cause aortic regurgitation ? (4)
    Dissection; Ankylosing Spondylitis; Marfans; Syphilis
  82. How is the pulse described in aortic regurgitation ?
    Water hammer
  83. How is the femoral artery murmur in aortic regurgitation described ?
    "Femoral artery ""pistol-shot"" murmur"
  84. What happens to arterial pulse pressure in AR ? Exception ?
    Widened (ie DBP <= 80); Except in severe AR -> LV end diastolic pressure rises
  85. What happens to the apex beat in aortic regurgitation ?
    Displaced and heaving
  86. Which added heart sounds are heard in aortic regurgitation ?
    S3 and S4
  87. Where can a thrill be palpated in AR ? Diastolic or systolic thrill ?
    Diastolic thrill at the lower left sternal edge
  88. What does a co-existing systolic thrill indicate ?
    May NOT signify significant aortic stenosis
  89. "What causes an ""Austin Flint"" murmur ?"
    Diastolic displacement of anterior mitral valve leaflet by AR
  90. "When does the ""Austin Flint"" murmur occur ?"
    Mid diastolic murmur
  91. What accentuates the auscultatory features of aortic regurgitation ?
  92. Which altered heart sounds are signs of aortic regurgitation severity ?
    Soft A2; S3
  93. What about the pulse in aortic regurgitation indicates severity ?
    Wide pulse pressure; collapsing pulse !
  94. What about a decrescendo diastolic AR murmur indicates severity ?
    Long decrescendo diastolic murmur
  95. Is an Austin-Flint murmur an indicator of AR severity ?
  96. Is left ventricular failure an indicator of severity in aortic regurgitation ?
  97. Which NYHA levels are indications for surgery in aortic regurgitation ?
  98. What determines outcomes in asymptomatic patients with left ventricular enlargement ?
  99. What defines frank left ventricular enlargement ?
    End diastolic diameter >= 55mm; LVEF < 55%
  101. What is the normal area of the mitral valve (cm2) ?
    Area 4-6cm2
  102. Significant mitral stenosis occurs at <2cm2; Severe mitral stenosis at <___ cm2 !
    Severe at < 1cm2
  103. What is the male:female ratio for mitral stenosis ?
    M:F = 1:2
  104. What are the causes of mitral stenosis ?
    Rheumatic; congenital (rare)
  105. Which cardiac rhythm is common in mitral stenosis ?
    Atrial fibrillation
  106. What facial feature is common in mitral stenosis ?
    Malar rash
  107. What happens to the JVP in mitral stenosis ?
    Prominent a wave
  108. What happens to the apex beat in mitral stensos ? S1 ?
    Tapping; palpable s1
  109. What heaves do we find in mitral stenosis ?
    RVH / Parasternal heave
  110. Which heart sound is palpable in mitral stenosis ?
    Palpable P2
  111. What happens to the first heart sound in mitral stenosis ?
    S1 accentualted / snapping
  112. What happens to P2 in mitral stenosis ?
    Loud P2
  113. What murmur occurs in mitral stenosis ?
    Mid diastolic rumbling murmur
  114. What causes the murmur in mitral stenosis to be accentuated ?
    Gentle exercise (pre-systolic accentuation)
  115. Which lesions are associated with mitral stenosis ?
    TM and MR
  116. Why is small pulse pressure a sign of severe mitral stenosis ?
    Increased LVEDP
  117. What feature of the murmur indicates severity ? When is it present ?
    Long diastolic murmur - as long as there is gradient between LA and LV
  118. Pulmonary _______ is a common feature of mitral stenosis !
    Pulmonary hypertension
  119. Which thrill is present in mitral stenosis ?
    Apical diastolic thrill
  120. What sound close to S2 indicates severity in mitral stenosis ?
    Opening snap slose to S2 (Increased LA pressure)
  121. What are the main indications for surgery in mitral stenosis ? (3)
    Usually valve area < 1cm2; CCF; Pulmonary Hypertension
  122. When should we suspect MR and MS ? (2)
    S3 (also suggestive of MR) and S1 (and or OS soft or absent)
  124. What are the main causes of tricuspid regurgitation ?
    Secondary Right Ventricular dilatation (functional); Secondary to IE in IVDU
  125. What is tricuspid regurgitation frequently associated with ?
    MR plus Pulmonary HTN
  126. How does a tricuspid regurgitation murmr present ?
    Pansystolic murmur at the left sternal edge; louder on inspiration
  127. How do the heart sounds change with tricuspid regurgitation ?
    Loud P2; PHTN
  128. What are the main features of tricuspid regurgitation ?
    Prominent v wave on JVP; pulsitile liver
  129. What heave occurs in tricuspid regurgitation ?
    Right ventricular heave
  131. What often causes a VSD ?
    Congenital; Ruptured MI
  132. What are the physical findings in VSD ?
    PSM maximal at lower LSE (can be loud with a small defect); S3/S4; Thrill softer with Valsalva
  133. What is a VSD often associated with ?
    Mitral regurgitation; downs syndrome and tetralogy of fallot
  134. What are the indications for surgery in VSD ?
    Moderate to large shunt
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Cardiology Murmurs
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