Cardiovascular Exam: Heart Sounds, Murmurs

valvular stenosis, valvular anomaly, congenital anomaly, increased blood flow

4 causes of murmurs?

dilated aorta, aortic valve disease, congenital stenosis

Aortic ejection sounds (Ej) are best heard at the base of the heart. Name the causes.

systolic, ejection, soft or vibratory, grade 1-2/6, no extra sounds, louder supine decreased intensity with: inspiration, sitting up, standing

Characteristics of innocent murmurs?

S2 and S1

Diastole is the interval between...?

aortic or pulmonary regurgitation

Early diastolic murmurs are due to...?

opening

Ejection sounds (Ej) = _______________ of pathologic valves.

CVD

Ejection sounds indicate what condition?

ejection sounds (aka clicks), aortic ejection or pulmonic ejection, mitral valve prolapse (MVP)

Explain the extra heart sounds that can occur in systole.

Grade 1 - barely audible Grade 2 - faint but immediately audible Grade 3 - easily heard Grade 4 - very loud

Explain the grading of diastolic murmurs.

Grade 1 - very faint Grade 2 - quiet, but heard immediately Grade 3 - moderately loud Grade 4 - loud Grade 5 - very loud, may be heard w/ stethoscope partially off of chest Grade 6 - may be heard with stethoscope completely off of chest

Explain the grading of systolic murmurs.

Deoxygenated blood enters enters the right side of the heart through the superior vena cava > flows from R side of heart to lungs via pulmonary artery Oxygenated blood returns from lungs via pulmonary veins to L side of heart > flows from L side of heart to systemic circulation via the aorta

Explain the perfusion circulation pathway of blood.

atrial septal defect (ASD)

Fixed splitting is seen in...?

palpable thrill

Grades 4 through 6 of systolic murmurs require the added presence of a...?

opening snap

Heard early in diastole, usually caused by opening of stenotic mitral valve Loud, high-pitched snapping sound Best heard medical to apex and along left sternal border

transient arterial occlusion, standing and squatting, valsalva maneuver, isometric handgrip

Important: Special Techniques to hear murmurs better List the 4 techniques.

Isometric handgrip

Increases systolic murmurs of mitral regurgitation, aortic regurgitation and also the diastolic murmurs of pulmonic stenosis and mitral stenosis

pericardial friction rub

Inflammation of pericardium gives rise to, high pitched and scratchy, like sandpaper being rubbed. Best heard w/ diaphragm, w/ person sitting up/leaning forward, w/ breath held in expiration. leads to mixed cycle murmur

Splitting

Instead of single heart sound, two discernible components (A2P2) Physiological splitting = separation of sounds accentuated by inspiration, which disappears with expiration Heard best over 2-3 left ICS close to sternum, near Erb's point. physiologic, wide, paradoxical

<120 bpm: systole shorter >120 bpm: systole longer

Is systole or diastole interval shorter when HR <120 bpm? What about when HR >120 bpm?

patent ductus arterioles (PDA) and combination murmurs

List 2 continuous murmurs.

pericardial friction rub, patent ductus arterioles (PDA), venous hum (continuous)

List 3 mixed cycle murmurs. Mixed cycle = murmur not confined to one aspect of cardiac cycle

systolic, mid-systolic, pansystolic

List the 3 timing systolic murmurs.

aortic regurgitation, pulmonic regurgitation, mitral stenosis, tricuspid stenosis, Austin-Flint murmur

List the types of diastolic murmurs that exist.

aortic stenosis, pulmonic stenosis, mitral regurgitation, tricuspid regurgitation, mitral valve prolapse, atrial septal defect, ventricular septal defect, hypertrophic cardiomyopathy

List the types of systolic murmurs that exist.

mitral stenosis

Mid-diastolic murmurs are due to..?

mitral regurgitation

Murmurs: Quality Which one is "blowing"?

atrial stenosis

Murmurs: Quality Which one is "harsh"?

innocent murmur

Murmurs: Quality Which one is "musical"?

Austin-Flint murmur - the result of regurgitant flow on the anterior leaflet of the mitral valve and turbulent mixing of antegrade and retrograde flow - low-pitched rumbling, apex - severe aortic regurgitation

Murmurs: Quality Which one is "rumbling"?

systolic, diastolic, continuous

Name the 3 types of murmurs.

opening snaps, S3 (ventricular gallop), S4 (atrial gallop

Name the 4 diastolic extra heart sounds.

friction rubs, Patent ductus arteriosus (PDA)

Name the extra heart sounds under Continuous sounds. - present in both systole and diastole

S1: mitral valve closure S2: aortic valve closure

On the left side, S1 = _____ closure, and S2 = _____ closure.

S1: tricuspid closure S2: pulmonic closure

On the right side, S1 = _____ closure, and S2 = _____ closure.

silent

Opening of valves is _________ except when pathology present.

left bundle branch block, aortic stenosis

Paradoxical splitting is seen in....?

stenosis (hardening or narrowing of valve, impedes blood flow through valve) regurgitation (failure of valve to close completely, allows for backflow of blood)

Pathologic murmurs arise from structural abnormalities in the heart or great vessels. State 2 examples.

fever or anemia

Physiologic murmurs are due to turbulence across a valve due to temporary increase in blood flow. They are secondary to systemic change. No true cardiac pathology. It can be caused by physiological changes in body. State 2 changes.

pulmonary artery dilatation, pulmonary hypertension, pulmonary stenosis

Pulmonic ejection sounds (Ej) are best heard at the 2-3 left intercostal spaces. Name the causes.

systole

RE: Cardiac physiology, Wiggers diagram Ventricular pressure rises during what phase of cardiac cycle?

"lub" - tricuspid and mitral valves close, beginning of systole

S1 heart sound represents what?

apex

S1 is usually the loudest at what area of the heart?

"dub" - aortic and pulmonic valves close, end of systole/beginning of diastole

S2 heart sound represents what?

base

S2 is usually the loudest at what area of the heart?

S1 and S2

Systole is the interval between...?

location, intensity, timing, pitch, quality, radiation

What 6 things are you looking for in murmurs?

closure of valves (and blood flow)

What action is responsible for heart valves?

crescendo, decrescendo, crescendo-decrescendo, plateau

What are the 4 shapes of murmurs?

1. ventricular relaxation and filling 2. aortic and pulmonary valves close (heart sound S2 - dub) 3. tricuspid and mitral valves open 4. blood flows into ventricles 5. atrial contraction

What occurs during diastole? x5

1. ventricular contraction 2. tricuspid and mitral valves close (heart sound S1 - LUB) 3. aortic and pulmonic valves open 4. blood pushed into the pulmonary artery and aorta

What occurs during systole? x4

Right contracts later than left

What side of the heart contracts slightly later than the other side?

right bundle branch block, pulmonic stenosis

Wide splitting is seen in...?

murmur

abnormal swishing sound caused by improper closure of the heart valves; often caused by turbulent blood flow through a valve - longer duration - can indicate disease or be benign - heard best over respective auscultatory areas for the involved valve

patent ductus arteriosus (PDA)

an abnormal opening between the pulmonary artery and the aorta caused by failure of the fetal ductus arteriosus to close after birth congenital abnormal opening b/w aorta and pulmonary arteries leads to mixed cycle murmur

fixed split S2

atrial septal defect (ASD) left to right shunt/flow, excess flow from left heart to pulmonary bed red = aortic valve (A2) blue = pulmonic valve (P2)

mid-systolic murmur

begins after S1 and stops before S2 most common type of murmur seen causes: innocent, pulmonic stenosis, atrial stenosis

Venous hum (continuous)

benign turbulent blood flow in jugular veins leading to mixed cycle murmur

S4 (atrial gallop, pathologic)

dull low-pitched sound, heard best with bell, heard late in diastole, just before S1 can be physiological but more often pathological causes: ventricular hypertrophy or fibrosis causing stiffness and increased resistance (or decreased compliance) during ventricular filling following atrial contraction results from decreased contractility of ventricle Left or Right Sided Left: apex in LLD position causes: HTN, atrial stenosis, ischemic and hypertrophic cardiomyopathy - "TEN-NES-SEE" Right: L sternal border Causes: pulmonary HTN, pulmonic stenosis

ejection sounds (aka clicks)

extra heart sounds in early systole, immediately after S1 coincident w/ opening of aortic or pulmonic valves high pitched, sharp clicking quality can affect either aortic Ej or pulmonic Ej sound: notice the clicking sound outside of the murmur noise

diastolic murmurs

failure of valve to close fully or turbulent blood flow across a stenotic valve always indicates heart disease heard between S2 and S1 (diastole) cycle can be early, mid, or late diastole causes: atrial regurgitation, mitral stenosis

Valsalva maneuver

forcible exhalation against a closed glottis after full inspiration, causing increased intrathoracic pressure able to ID - Hypertrophic obstructive cardiomyopathy (HOCM), HF, pulmonary HTN

mitral valve prolapse (MVP)

improper closure of the mitral valve most common = abnormal ballooning of part of mitral valve heard best medial to apex or along the left sternal border; best heard when patient is in left lateral decubitus position heard mid to late; often associated with systolic murmur high-pitched click sound

pansystolic murmur (holosystolic)

murmur caused by flow of blood across a valve from high to low pressure pathologic, heard throughout S1 - S2 cycle causes: mitral regurgitation, tricuspid regurgitation, ventricular septal defect (VSD)

S3 (ventricular gallop, pathologic)

pathologic, decrease in contractility and volume overload due to valve incompetence cause: heart failure heard in early diastole, can occur in R or L side L-sided heard best at apex in left lateral decubitus position R-sided heard best at L sternal border, supine position, louder on inspiration "KEN-TUC-KY"

S3 (ventricular gallop, physiologic)

physiological, extra diastolic heart sound is heard early in diastole during rapid ventricular filling >>> physiologic in children, can occur in last trimester of pregnancy, pathological in those over 40 years old (think heart failure) low-pitched, heard best with bell at the apex in left lateral decubitus position

paradoxical split S2

seen in conditions that prolong left ventricle (LV) emptying (aortic stenosis, left bundle branch block) split "eliminated" on inspiration red = aortic valve (A2) blue = pulmonic valve (P2)

widened split S2

seen in conditions that prolong right ventricle (RV) emptying (pulmonic stenosis, right bundle branch block) red = aortic valve (A2) blue = pulmonic valve (P2)

pathological splitting

splitting that persists throughout respiratory cycle, suggestive of heart disease 3 types: fixed, wide, paradoxical

transient arterial occlusion

transient compression of both arms by bilateral blood pressure cuff inflation to 20 mmHg greater than peak systolic blood pressure augments the murmurs of mitral regurgitation, atrial regurgitation, ventricular septal defect

innocent (aka Still's) murmur

turbulent blood flow across valve due to strong ventricular ejection of blood short duration and mid-range frequency (mid-systolic) crescendo-decrescendo or "diamond" shaped common in children, young adults no evidence of CVD no physiological or structural abnormalities BEST HEARD at APEX of heart, and left lateral border with BELL

standing and squatting

used for Hypertrophic obstructive cardiomyopathy (HOCM) - increase in intensity during squatting-to standing action and by a decrease in intensity during standing-to-squatting action