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heart murmurs (PANCE prep pearls)

Terms in this set (52)

Aortic stenosis pathophysiology
left ventricle outflow obstruction leads to fixed cardiac output and increased after load
causes of aortic stenosis
- degenerative calcifications, esp >70 yrs old
- congenital and bicuspid valve, more common <70 yrs old
most common sx of aortic stenosis
exertional dyspnea
aortic stenosis murmur
harsh systolic murmur crescendo decrescendo best heard at the RUSB and radiates to carotids/neck
position that increases all aortic murmurs
sitting while leaning forwards
valsalva and standing increase/decrease venous return
decrease
squatting, supine, and leg raise increase/decrease venous return
increase
Heart sound associated with aortic stenosis
S4
ECG findings associated with aortic stenosis
left ventricular hypertrophy, left atrial enlargement, and a fib
CXR findings associated with aortic stenosis
nonspecific - postaortic dilatation, aortic valve calcifications, and pulmonary congestion
definitive diagnosis of aortic stenosis
cardiac catheterization
treatment of choice for aortic stenosis
aortic valve replacement (only effective tx)
characteristics of mechanical heart valves
- prolonged durability but thrombogenic and therefore long term anticoagulation required
- recommended for patients <50 yrs
characteristics of bioprosthetic heart valves
- less durable but minimally thrombogenic
- recommended for patients >70 yrs old
treatment for aortic stenosis in pediatric pts or pts that aren't valve replacement candidates
percutaneous aortic valvuloplasty
what should be avoided in pts with severe aortic stenosis prior to surgery? why?
avoid physical exertion, venodilators like nitrates, CCBs, and BBs (negative inotropes)

pts are dependent on preload to maintain cardiac output (so avoid things that decrease preload)
aortic regurgitation pathophysiology
incomplete aortic valve closure leading to regurgitation of blood through aortic valve during diastole
Most common causes of acute aortic regurgitation
endocarditis and aortic dissection
chronic aortic regurgitation causes
congenital bicuspid valve, RHD, HTN, autoimmunity, syphilis, Ehlers danlos, and marfan's
acute aortic regurgitation presentation
- increase preload and afterload
- LV diastolic pressure rises rapidly leading to acute pulmonary edema and increase pulmonary capillary wedge pressure
- cardiogenic shock
aortic regurgitation murmur
High-pitched "blowing" early diastolic decrescendo or sustained murmur best heard over Erbs point ( 3rd or 4th ICS)
Austin Flint murmur
mid-late diastolic rumble at the apex secondary to retrograde regurgitant jet competing with antegrade flow from left atrium to left ventricle
Water hammer pulse
Bounding pulses commonly seen in aortic regurgitation (seen due to widened pulse pressure)
three most common PEx signs of chronic aortic regurg
water hammer pulse, corrigan's pulse, and Hill's sign
Corrigan's pulse
bounding carotid pulse
Hill's sign
popliteal artery systolic reassure > brachial artery by 60mmhg (most sensitive for chronic AR)
De Musset's sign
head bobbing with each heartbeat (assoc. with chronic AR with low sensitivity)
Quincke's pulses
visible fingernail bed pulsations with light compression of fingernail bed (Quincke's in the pinky!)
- assoc. with aortic regurg
Muller's sign
visible systolic pulsations of uvula seen in chronic AR (d/t widened pulse pressure)
definitive tx for aortic regurg
aortic valve replacement
medical management for aortic regurg
focus on afterload reduction - ACEi, ARB, Nifedipine, or hydralazine
mitral stenosis pathophysiology
inc left atrial pressure and volume overload → pulmonary congestion → pulmonary HTN → CHF
Most common cause of mitral stenosis
rheumatic heart disease

(other causes → congenital, left atrial myxoma, thrombus, valvulitis (SLE, amyloid, carcinoid))
mitral stenosis clinical presentation
- exertional dyspnea (MC), hemoptysis, pulmonary HTN (if Hx RF, then may occur in 20-30s)
- A fib
- mitral facies (ruddy/flushed cheeks with facial pallor)
mitral facies
pinkish purple patches on cheeks - sign of mitral stenosis
Ortner's syndrome
recurrent laryngeal nerve palsy due to compression of dilated left atrium → hoarseness
- can be associated with mitral stenosis
Mitral stenosis murmur
low pitched, mid diastolic rumble with opening snap best heard at mitral area/apex (left 5th ICS at MCL)
positions that increase mitral stenosis
left lateral decubitus, expiration, and increased venous return (squatting, leg raise, and supine)
who are candidates for percutaneous balloon valvuloplasty for patients with mitral stenosis? what is the alternative?
symptomatic, young patients with no calcified valves or if refractory to medical therapy

alt. → valve replacement if mitral valvuloplasty is contraindicated or has unfavorable valve morphology
MC cause of mitral regurgitation in the US? other causes?
mitral valve prolapse

other → endocarditis, valvulitis, annulus, LV dilation, marfan
mitral regurgitation murmur
High-pitched blowing systolic murmur best heard at apex and radiates to left axilla/subscapular region
what positions increase mitral regurgitation
left lateral decubitus, expiration, increased venous return
valsalva and standing increase/decrease mitral regurgitation
decrease
Tx for HTN + mitral regurgitation
afterload reducers → ACEi, ARB, hydralazine, nitrates

(ACEi and ARBs have also been used to delay mitral regurg progression)
acute mitral regurg treatment
urgent surgical or percutaneous intervention
mitral valve prolapse is most common in...
young women, usually 15-25 yrs old
marfan's, ehlers-danlos, osteogenesis imperfecta
mitral valve prolapse murmur
mid-late systolic click best heard at apex

click may be followed by the high pitched mid-late systolic murmur of mitral regurg
what can delay the click in mitral valve prolapse
any maneuver that increases preload → squatting, leg raise, supine)
echocardiogram findings c/w mitral valve prolapse
displacement of any portion of mitral leaflets 2 mm or more above the annular plane into the left atrium
on PEx you hear a mid-late systolic click. Pt denies any symptoms. How do you manage this pt?
reassurance (dx MVP)
pulmonic regurgitation etiology
primary → almost always congenital
secondary → pulm HTN, pulm artery dilation, tetralogy of fallout, endocarditis, or RHD
pathophysiology of pulmonary regurg
retrograde blood flow from pulmonary artery into RV → right sided volume overload
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