3Cardiac Auscultation Murmurs Systolic Ejection – Implies either obstruction or high outputObstruction: AS, HOCM, rarely PSHigh output: Anemia, Thyrotoxicosis, AR, ASD, VSDInnocent murmur: Mid-systolic, best at LSB, non radiatingPansystolic – Implies retrograde flow from high to low pressure chamberMR, TR, VSD
6Aortic StenosisSystolic ejection murmur that usually peaks in early systoleLocation: Classically heard best in right 2nd interspaceAs the degree of AS worsens, the murmur peaks closer to S2 (i.e. later).In general, the later the peak and the louder the murmur, the more severe the stenosis.Often radiates to the carotidsCarotid upstrokes are delayed!In reality, often loudest in a “sash” or “shoulder harness” area from second right interspace to apex
7HOCM Caused by outflow tract obstruction Location: 3rd or 4th left interspacesCan sound just like AS unless you do maneuvers!Increasing size of LV makes murmur softerSquatting (raises BP)Decreasing size of LV makes murmur louderValsalva (↑intrathoracic pres ↓VR↓LV)Valsalva: HOCM gets louder, AS gets softerSquatting: HOCM gets softer, AS gets louder
8Mitral Regurgitation Holosystolic murmur Location: Heard best at the apexRadiates to the axillaPearl: Presence of S3 suggest severe MRBonus trivia: What is the Gallavardin phemonena?
9Mitral StenosisCauses either (or both) an opening snap or a diastolic rumble.Location: apexMore bonus (read: useless) trivia: What is the Austin Flint murmur?
10Aortic Regurgitation Early diastolic murmur. “Blowing.” Often associated with systolic ejection murmur from high stroke volumeLocation: Heard best at LSB in 3rd or 4th IC spaceWide pulse pressure
11Tricuspid Regurgitation Holosystolic murmurCauses: RV failure and dilation, Pulmonary hypertension of any causeLocation: Heard best at left lower sternal bordererClues:Intensity may increase with inspirationLook for large v waves in neck veins
12Pearls PDA ASD VSD AV Dissociation MVP Continuous, “machine-like” murmurASDFixed split S2VSDUsually a pansystolic murmurAV DissociationCannon AV waves, pounding in neckMVPMid-systolic clickdifferent from an opening snap which is diastolic
14Pearls Normal heart sounds: A Right Bundle Branch Block delays P2 causinga “widely split S2” which is a persistent split thatwidens with inspiration:S1A2P2S1A2P2
15Pearls Normal heart sounds: A Left Bundle Branch Block delays A2 causinga “paradoxically (or reversed) split S2” which isa split that occurs with expiration and disappearswith inspiration:S1P2A2S1S2
16Question 11. A 60-year old man has a 2-month history of progressive dyspnea and chest pain. Cardiac auscultation reveals a grade 3 systolic ejection murmur that is heard best at the second right interspace. The murmur radiates into the carotid arteries. What is the most likely underlying valvular abnormality?1. Aortic regurgitation2. Aortic stenosis3. Mitral regurgitation4. Mitral stenosis
17Answer 1Aortic stenosis. Systolic ejection murmurs are caused by outflow obstruction. Their intensity peaks in midsystole and is described as a crescendo-decrescendo or “diamond-shaped” murmur. The murmur of aortic stenosis is an example of a systolic ejection murmur. The murmur radiates along the outflow track (ie, into the carotid arteries).
18Question 2A 50-year-old woman has a 3-month history of progressive dyspnea. Cardiac auscultation reveals a grade 3 pansystolic murmur heard best at the apex. The murmur is medium-pitched and radiates to the axilla. What is the most likely underlying valvular abnormality?1. Aortic regurgitation2. Aortic stenosis3. Mitral regurgitation4. Mitral stenosis
19Answer 2Mitral regurgitation. Pansystolic murmurs are almost always caused by reverse flow across a valve. The single exception occurs in cases of a ventricular septal defect, in which blood flows across an orifice in the septum. The murmur of mitral regurgitation radiates into the axilla in the direction of the flow.
20Question 3A 40-year-old woman has a 3-month history of progressive dyspnea. Cardiac auscultation reveals a grade 3 diastolic murmur heard best at the apex. The murmur is low-pitched and has a rumbling quality. There is a snapping sound that immediately precedes the murmur. What is the most likely underlying valvular abnormality?1. Aortic regurgitation2. Aortic stenosis3. Mitral regurgitation4. Mitral stenosis
21Answer 3Mitral stenosis. The murmur of mitral stenosis is generated during left atrial contraction as blood is being forced through the narrowed mitral valve. There is usually an opening snap just before the diastolic rumble begins.
22Question 4During a routine physical examination of a 30-year-old man, cardiac auscultation reveals a grade 3 systolic ejection murmur heard best at the left lower sternal border. The murmur does not radiate into the carotid arteries and becomes louder when the patient is asked to perform the Valsalva maneuver. What is the most likely underlying cardiac abnormality?1. Aortic stenosis2. Dilated cardiomyopathy3. Hypertrophic cardiomyopathy4. Mitral regurgitation
23Answer 4Hypertrophic cardiomyopathy. Systolic ejection murmurs are caused by outflow obstruction. In this case, the obstruction of the outflow tract results from asymmetrical hypertrophy of the ventricular septum. The murmur is worsened with performance of the Valsalva maneuver, because the outflow obstruction is increased.
24Question 5During a routine physical examination of a 15-year-old boy, cardiac auscultation reveals a grade 3 systolic ejection murmur heard best at the left second interspace. S2 is widely split and fixed (ie, does not vary with respirations). What is the most likely underlying cardiac abnormality?Atrial septal defectVentricular septal defectAortic stenosisPulmonic stenosis
25Answer 5Atrial septal defect. The systolic ejection murmur produced by an atrial septal defect results from increased flow across the pulmonic valve. The right ventricle has increased filling as blood is shunted from the left atrium to the right atrium and finally into the right ventricle. There is fixed splitting of S2 because of continued delay in the closure of the pulmonic valve.
26Question 6A 20-year-old female is evaluated for palpitations. She has noticed rapid pounding in her chest on several occasions. She is most aware of pounding in her neck. Most episodes last less than 1 minute, but a few have lasted one half hour. During an episode she is lightheaded, but does not have syncope, chest pain, or shortness of breath. Symptoms usually occur without warning at rest. If she breathes slowly and deeply, the episodes usually stop on their own. Recently, the episodes have been more frequent. Her EKG and physical exam are normal.Which is the most likely diagnosis?1. Benign premature atrial contactions2. Palpitations related to MVP3. Paroxysmal SVT4. Ventricular Tachycardia5. Paroxysmal atrial flutter
27Answer 6Paroxysmal SVT. Aburpt onset and regularity of patient’s symptoms suggest SVT. The pounding in the neck is related to cannon A waves, caused by atrial contraction against a closed valve. PSVT in young women is usually AVNRT and is much more common than than VT or Aflutter.
28Question 7A 25-year-old pregnant woman is referred to you because of a heart murmur noted during the second trimester of pregnancy (her first pregnancy). The patient has no history of cardiac disease and the murmur was not noted during previous exams. She is asymptomatic. Exam shows a mildly displaced apical impulse and lower extremity edema. S1 and S2 are normal and an S3 is noted at the apex. A grade 2/6 early to mid-peaking systolic murmur is audible at the left sternal border.Which of the following is most likely?1. Bicuspid aortic valve with mild to moderate stenosis2. Congenitally abnormal pulmonary valve with moderate stenosis3. Physiologic murmur related to pregnancy4. Mitral valve regurgitation related to MVP5. Bicuspid aortic valve with moderate regurgitation
29Answer 7Physiologic murmur related to pregnancy. S3 is audible in 80% of pregnant women. An early peaking ejection systolic murmur (flow murmur) is audible in 90% of pregnant women. Apical displacement is common because of the increase in blood volume the occurs in later pregnancy.
30Question 8A 26-year-ol man seeks your advice because he was diagnosed as having a heart murmur as a baby. At that time, his parents were told he would “outgrow” the murmur. The patient participates actively in sports without any cardiac symptoms. On physical exam, S1 is normal, S2 is physiologically split. A thrill is noted in the third left intercostal space and a 4/6 holosytolic murmur is noted along the left sternal border radiating to the right. No S3 or S4 are heard.Which of the following is most likely?1. Aortic stenosis2. Mitral regurgitation related to MVP3. VSD4. Cardiomyopathy
31Answer 8VSD. VSD’s create very loud heart murmurs that are holosystolic (often they also cause a thrill). None of the other answers fit with the exam.
32Question 9A 42-year-old woman comes to your office for evaluation of angina and dyspnea on exertion for 6 months. She has no cardiac history other than a long standing murmur. On physical exam, she has a normal S1 and S2. An S4 is noted. She has a grade 2/6 late-peaking systolic ejection murmur that increases with valsalva as well as when she rises from squatting to standing.Which of the following is most likely?1. Aortic Stenosis2. HOCM3. Mitral Regurgitation4. VSD
33Answer 9HOCM. Angina and dyspnea are symptoms of progressive obstruction. While this can also be cause by AS, a murmur that increases with valsalva (i.e. deceased preloaddecreased LV size) is consistent with HOCM.