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