Heart Murmurs Part 1

PA Study Sesh

During this week’s episode, we’ll be discussing valvular disorders, in essence, heart murmurs.
There are LOADS of Picmonics available for heart murmurs. A couple of my favorites Mitral Regurgitation and Aortic Stenosis.
Systole=ventricles contracting
Diastole=ventricles relaxing & refilling
S1=beginning of systole. AV valves (mitral & tricuspid) are closing. “lub”
S2=end of systole. Semilunar valves closing (aortic & pulmonic) “dub”
Lub, dub, rest, lub, dub, rest
Murmur Accentuation Maneuvers
The following applies to all murmurs except that of hypertrophic cardiomyopathy, in which the opposite is true
* Position:
* Aortic=increased with leaning forward
* Mitral=LLD
* Increased venous return
* Squatting
* Leg raise
* Lying down
* Later click in MVP
* Inspiration
* Right sided murmurs only
* Also due to increased venous return
* Expiration
* Left sided murmurs only
* Also due to increased venous return
* Increased Afterload
* Handgrip
* Increases regurgitation murmurs
* Pushes backward
Aortic Stenosis
* #1 valvular disease
* Etiologies:
* Calcification
* Bicuspid valve (if under 70y.o.)
* Systolic, crescendo-descrescendo ejection murmur
* At right upper sternal border (the location of the aortic valve)
* With radiation to the carotids
* Narrowed pulse pressure
* Pulsus parvus et tardus
* Small, delayed, carotid pulse
* Not specific to aortic stenosis
* Can lead to angina, syncope, LVH, and CHF
* Tx:
* VALVE REPLACEMENT
* Once symptomatic
* Mechanical valves (vs bioprosthetic) require lifelong anticoagulation
Mitral Stenosis
* Etio: rheumatic heart disease
* Early mid-diastolic rumble preceded by an opening snap
* At apex (location of mitral valve)
* Increased in left lateral decubitus position
* Prominent S1 (stenotic mitral valve closes forcefully)
* Symptoms
* Pulmonary symptoms
* Blood backs into lungs
* Pulmonary htn
* Atrial fibrillation
* 2/2 atrial enlargement
* “mitral facies”
* Flushed cheeks with facial pallor
* Treatment:
* Percutaneous balloon valvuloplasty
* Younger patients
* Non-calcified valves
* Valve replacement otherwise
Mitral Regurgitation
* Etio:
* mitral valve prolapse #1
* papillary muscle dysfunction
* ischemia/infarction
* Blowing, holosystolic murmur
* At Apex (location of mitral valve)
* Radiation to axilla
* Blowing=regurg
* Widely split S2
* Aortic valve closes early due to decreased LV ejection time
* Pulmonic valve closes late due to pulmonary htn (increased pressure to overcome)