Heart Sound

Aortic Stenosis MCC, Sx, Tx

- MCC: atherosclerosis (older pt) - Sx: CP, CHF, Syncope little blood gets through aortic valve so heart dialate, then lead to HF and blood pools Tx: Valve replacement Systolic murmur

Pulmonary regurgitation

- diastolic murmur - inc with insp & dec w/ valsalva

Which of the following best describes the physiologic process responsible for the fourth heart sound heard in patients with advanced aortic stenosis? AAtrial contraction against a noncompliant left ventricleCorrect Answer BBlood striking a dilated left ventricle during diastoleYour Answer CDelayed closure of the aortic valve in relation to the pulmonic valve DTurbulent blood flow across a calcified aortic valve

A In aortic stenosis, the aortic valve becomes hardened and its leaflets do not fully open during systole, causing classic crescendo-decrescendo systolic murmur. As the aortic valve becomes more calcified and less mobile, the left ventricle must work harder during systole to eject its blood volume and therefore becomes hypertrophied and less compliant. Atrial contraction against this noncompliant left ventricle leads to an audible and prominent fourth heart sound (S4). Aortic stenosis also leads to a fixed stroke volume despite vasodilation and often a subsequent decline in systemic blood pressure. Such a decline can lead to exertional syncope. The classic triad of symptoms seen with aortic stenosis is chest pain, dyspnea, and syncope. On physical exam, a patient with aortic stenosis will have a classic crescendo-decrescendo systolic murmur best auscultated at the right sternal border and will have an absent or delayed aortic component of the second heart sound (A2) due to calcified and immobile aortic valve leaflets. Treatment of aortic stenosis in patients who are symptomatic involves percutaneous balloon valvuloplasty or surgical replacement of the aortic valve. Blood striking a dilated left ventricle during diastole (B) will produce a third heart sound (S3). The third heart sound comes immediately after the second, is low-pitched, and is heard best at the apex in the left lateral decubitus position. Healthy individuals with a very compliant left ventricle may have an S3, but the presence of an S3 can also indicate pathologies such as dilated cardiomyopathy and systolic heart failure. Delayed closure of the aortic valve in relation to the pulmonic valve (C) will produce a paradoxical splitting of the second heart sound (S2). Patients with aortic stenosis may demonstrate a paradoxically split S2 because the aortic valve leaflets have become calcified and stiff, which delays their closure in relation to the pulmonic valve. A split S2 is best heard at the pulmonic listening post (second intercostal space to the left of the sternum). Turbulent blood flow across a calcified aortic valve (D) is responsible for the classic crescendo-decrescendo systolic murmur of aortic stenosis but not for the S4.

How is an S3 distinguishable from a split S2?

Answer: An S3 is low-pitched and best heard with the bell of the stethoscope at the apex. A split S2 is high-pitched and best heard with the diaphragm of the stethoscope at the pulmonic listening

Systolic Murmur

Aortic Stenosis, Mitral regurgitation

MItral Vavle prolapse is what?

Eti: congenital. usu young F - Leaflet do not touch well b/c too big so blow through. - Murmur better when ventricle stretch out (more blood) Tx: avoid dehydration and BB (sustained preload and give more time filling)

More blood & less murmur

Hypertrophy Cardiomyopathy Mitral valve prolapse

A 65-year-old woman with no known illness presents with dyspnea and a grade 3/6 systolic murmur. Which of the following would suggest the diagnosis of aortic stenosis rather than mitral valve regurgitation? AHyperdynamic left ventricleYour Answer BMurmur best heard at apex CProminent fourth heart soundCorrect Answer DWide splitting of S2

In aortic stenosis, the aortic valve becomes hardened and its leaflets do not fully open during systole, causing a harsh holosystolic murmur. Aortic stenosis also leads to a fixed stroke volume despite vasodilation and often a subsequent decline in systemic blood pressure. Such a decline can lead to exertional syncope. The classic triad of symptoms seen in patients with aortic stenosis is chest pain, dyspnea, and syncope. On physical exam, a patient with aortic stenosis will have a harsh holosystolic murmur best auscultated at the right sternal border and will have an absent or delayed aortic component of the second heart sound due to calcified and immobile aortic valve leaflets. As the aortic valve becomes more calcified and less mobile, the left ventricle must work harder during systole to eject its blood volume and therefore becomes hypertrophied. This leads to an audible and prominent fourth heart sound (S4). Mitral valve regurgitation occurs when the leaflets of the mitral valve do not fully close during systole, allowing retrograde flow of blood from the left ventricle to the left atrium. Longstanding mitral valve regurgitation can lead to increased intracardiac pressure and left ventricular dysfunction. This dysfunction presents itself on physical exam as a hyperdynamic left ventricle (A) and a third heart sound (S3). Patients with chronic mitral valve regurgitation may suffer fatigue, dyspnea, or palpitations. On physical exam, a patient with longstanding mitral valve regurgitation will demonstrate a high-pitched, blowing systolic murmur best heard at the apex (B) and which radiates to the left axilla, as well as a wide splitting of S2 (D) due to early closure of the aortic valve. Transesophageal echocardiography is the preferred modality for definitive diagnosis of mitral valve regurgitation.

Mitral valve stenosis & MCC

Loud S1 Opening snap diastolic apical murmur - group a beta hemolytuc streptococcus

Mitral Stenosis's MCC, Sx, Tx

MCC: Rheumatic Heart dz. usu younger pt Sx: CHF, Afib (d/t atrium dilation) Tx: Ballon valvuloplasty (angioplasty of valve) to open up the valve. - Last: replacement

Aortic insufficiency MCC, Sx, Tx

MCC: infection or infarction. aorta dissection - Acute: cardiogenic shock, flash Pulm edema +/- CP - Chronic: CHF sx +/- CP Dx: Tx: replacement (chronic or emergent) blood flow back to ventricle and pools

Mitral regurgitation MCC, Sx, Tx

MCC: infxn, infarction Sx: - Acute: cardiogenic shock, pulm edema - Chronic: HF, +/- Afib Tx: replacement

Dilated Cardiomyopathy

S3 gallop d/t filling dilated ventricle

Diastolic Murmur

Mitral Stenosis, Aortic insufficiency, Pulmonary regurgitation.

More blood in heart & more murmur are

Mitral Stenosis, Mitral regurg, Aortic Stenosis, Aortic regurg

Vavles

The Epstein anomaly is the abnormal development of the septal and posterior leaflets of the tricuspid valve (B). This abnormality leads to tricuspid regurgitation, which has a characteristic holosystolic murmur, not a diastolic murmur. Congenital rubella is associated with pulmonary stenosis and peripheral vascular stenosis (C). Calcification of the aortic valve may result in narrowing of the aortic valve, known as aortic stenosis. However, the murmur associated with aortic stenosis is a crescendo-decrescendo mid-systolic murmur that radiates to the neck, making calcification of the aortic valve leaflets an incorrect option (D). Mitral valve prolapse often occurs when there is a congenital abnormality of the chordae tendineae, resulting in elongation (E). The elongation results in billowing of mitral valve leaflets back into the atrium, which may be auscultated as a mid-systolic click. If the defect is severe, mitral valve prolapse may lead to mitral regurgitation, which is a pansystolic murmur.

Aortic Stenosis

crescendo-decrescendo mid-systolic murmur radiates to neck - Best at Base

Hypertrophic Cardiomyopathy

harsh crescendo-decrescendo systolic murmur at L sternal border increases in intensity with Valsalva maneuver decreases with squatting -sounds like aortic stenosis but murmur dec when more blood

Mitral regurgitation murmur

high pitch and blowing. Pansystolic (holosystolic) murmur best at apex & radiates to axilla - Systolic murmur

Tricupsid regurgitation

holosystolic murmur

Aortic Insufficiency/Regurgitation murmur

rumbling diastolic murmur at base. 2nd ICS Rt sternal border.

Mitral Stenosis sounds like and location

rumbling diastolic w/ opening snap Murmur - Heard best at Apex (5th ICS mid clavicular

Hypertrophy Cardiomyopathy murmur

sound like aortic stenosis but murmur better w/ more blood

Mitral valve prolapse murmur

sound like mitral regurg but murmur better w/ more blood

Hypertrophy Cardiomyopathy MCC

unilateral septum hypertrophy and cover aortic opening and obstruct blood outflow. - Eti: Young athlete - Tx: BB and avoid dehydration (sustained preload and give more time filling) - Question: SOB, syncope w/ exertion or family hx of sudden death