Heart Disease Braunwald Chapter 4 Physical Examination (II) --- Heart Murmur Presenter: R4 劉嚴文
Cardiac Auscultation Heart Murmur Characteristics of heart murmur Timing in the cardiac cycle Intensity (loudness) Frequency (pitch) --- from high to low Configuration (shape) --- crescendo, decrescendo, crescendo-decrescendo (diamond-shaped), plateau (even) or variable (uneven) Quality Duration Direction of radiation
Cardiac Auscultation Heart Murmur
Cardiac Auscultation Heart Murmur Heart murmurs broad categories Systolic: begin with / after S1 end at / before S2 2 terms out of time Regurgitant systolic murmur (holosystolic murmur) Ejection systolic murmur (midsystolic murmur) Diastolic: begin with / after S2 end at / before the subsequent S1 Continuous: begin in systole and continue without interruption through the S2 into all / part of diastole
Midsystolic Murmurs Etiologies Obstruction to ventricular outflow Dilatation of the aortic root or pulmonary trunk Accelerated flow into the normal aorta or pulmonary trunk, as during pregnancy, fever, thyrotoxicosis, or anemia Innocent (normal) midsystolic murmurs Some forms of MR
Aortic Valve Stenosis Symmetrical diamond shape High-velocity jet within the aortic root radiation of the murmur upward to the right 2nd intercostal space and the neck
Aortic Valve Stenosis In old adults, aortic valve with sclerotic or stenotic change resulted from fibrocalcific change : R’t 2nd ICS: impure, noisy, harsh (jet turbulence) LV impulse: pure, musical (from periodic high-frequency vibrations of the fibrocalcific aortic cusps) ( Gallavardin dissociation --- Noisy right basal and musical apical )
Aortic Valve Stenosis D/D from high-pitch apical murmur of MR VPC followed by pauses longer than the dominant cycle length Intensity of AS: increase Intensity of MR: unchange
Pulmonary Valve Stenosis Location: Right side of the heart Length and configuration: signs of severity
Still Murmur Normal vibratory midsystolic murmur Short, buzzing, pure and medium in frequency Generated by low-frequency periodic vibrations of normal pulmonary leaflets or a left LV false tendon Typically heard between LLSB and apex
Innocent Midsystolic Murmur Location: second left intercostal space Aortic sclerotic murmur (most common) Exaggeration of normal ejection vibrations within the pulmonary trunk: relatively impure, best heard in the left 2nd ICS. In patients with diminished anteroposterior chest dimension
Midsystolic Murmur from MR Usually in ischemic heart disease associated with LV regional wall motion abnormalities. Impaired integrity of the muscular component of the mitral apparatus Early systolic competence of the mitral valve Midsystolic incompetence Late systolic decline in regurgitant flow
Holosystolic Murmurs A persistent high pressure / resistance systolic flow to a low pressure / resistance vascular bed Left heart: MR Right heart: TR Between the ventricles: a restrictive VSD Between the great arteries: Aortopulmonary connection (pulmonary vascular resistance rise to abolish the diastolic portion of the continuous murmur)
Holosystolic Murmurs Direction of radiation of MR Jet forward and medial against the atrial septum near the origin of the aorta: murmur radiation to the left sternal edge, base and neck Jet posterolateral with the LA: murmur radiation to the axilla, left scapula angle and the vertebral column with bone conduction from the C spine to L spine
Holosystolic Murmurs Diagnostic feature of TR Carvallo sign --- inspiratory increase in loudness Due to increase RV volume during inspiration Stroke volume ↑ Regurgitant flow velocity ↑
Early Systolic Murmurs Begins with S1, diminish in decrescendo and end well before S2, generally at or before midsystole Certain types of acute severe MR, TR and VSD
Early Systolic Murmurs A feature of TR with normal RV systolic pressure, ex. TR caused by IE VSD A small VSD (constrictive): a soft, pure, high-frequency, early systolic murmur localized to the mid- or lower left sternal edge A non-constrictive VSD with elevated pulm. vascular resistance
Late Systolic Murmurs Begin in mid- to late systole and proceed up to S2 Prototype: Mitral valve prolapse Response to postural maneuvers / amyl nitrite Prompt standing after squatting / valsalva maneuver: longer and softer Squatting / handgrip (LV volume↑): shorter and louder An intermittent, striking systolic whoop or honk -- spontaneously or in response to maneuvers: from mitral leaflets and chordae tendineae
Heart Murmur Diastolic murmur Early diastolic murmur AR, PR Mid-diastolic murmur MS, TS and atrial tumors, increase flow through non-obstructive AV valve Late diastolic murmur Austin-Flint murmur
Early Diastolic Murmurs --- AR Left side of the heart, esp. with the diaphragm of the stethoscope From primary valvular disease: best heard along the left sternal border in the 3rd and 4th intercostal space From ascending aorta dilatation: along the right sternal border Esp. leaning forward and during a held, deep exhalation Beginning immediately after A2, high frequency
Early Diastolic Murmurs --- AR Chronic AR Moderate: murmur throughout diastole Severe: more obvious decrescendo Radiation to the right sternal edge: aortic root dilatation, as in Marfan syndrome
Early Diastolic Murmurs --- Acute AR D/D from chronic AR Often loud, Grade 4 Quite soft, Grade 2
Early Diastolic Murmurs Graham Steell murmur (of pulmonary hypertensive pulmonary regurgitation) Begin with loud P2 High pulmonary pressure on the incomplete P valve High diastolic pressure gradient between the pulmonary artery and the RV High-velocity regurgitant flow High-frequency blowing murmur, throughout diastole Amplitude of the murmur: uniform throughout most of diastole
Mid-Diastolic Murmurs Mitral stenosis Following the mitral opening snap, originating within the LV, transmission to the chest wall, maximal over the LV impulse Left lateral decubitus position Vigorous voluntary cough or a few sit-ups HR and mitral valve flow ↑ Murmur reinforced
Mitral stenosis In Af, duration of the murmur is a sign of the degree of obstruction at the mitral orifice In sinus rhythm
Mid-Diastolic Murmurs Tricuspid stenosis D/D from MS: Loudness of tricuspid murmur ↑with inspiration Tricuspid murmur confined to a localized area along the left lower sternal edge
Late Diastolic Murmurs Occur immediately before S1 Usually originate at the mitral or tricuspid orifice because of obstruction (MS, TS) Tricuspid stenosis: crescendo-decrescendo. Fading before S1 Austin-Flint murmur in AR
Continuous Murmurs PDA (loudest in left 2nd ICS) Coronary AV fistula (loudest in lower sternal border) Ruptured sinus of Valsalva aneurysm (loudest in right upper sternal border)
Continuous Murmurs Arteriovenous continuous murmurs Arterial continuous murmurs Continuous venous murmur Innocent cervical venous hum: the most common type of normal continuous murmur, in healthy children and healthy young adults, esp. pregnancy Thyrotoxicosis and anemia
Heart Murmur Approach
Approach to the Patient with a Heart Murmur Cardiac echo is indicated as follows: Loud murmur (>= grade 3) Holosystolic or late systolic murmur Systolic murmur becomes louder or longer during Valsava maneuver (susp. HOCM or MVP) Systolic murmur with clinical findings suggesting IE, thromboembolism or syncope Systolic murmur associated with abnormal EKG
Heart Murmur Pericardial Rubs Triple phases midsystolic, middiastolic and late diastolic Detected in Acute pericarditis
Dynamic Auscultation Respiration Diastolic sounds and ejection sounds S3, S4, opening snap From right heart: augmented during inspiration From left heart: diminished during inspiration Ejection sounds intensity Right heart, ex. PS: ↓ during inspiration Left heart: not effected, except tetralogy of Fallot Murmur: more pronounced on the right side murmur ( Venous return increase during inspiration ) ↑during inspiration: TS, PR (diastolic murmur), TR and Ebstein anomaly (presystolic murmur), MVP
Dynamic Auscultation Valsalva Maneuver
Dynamic Auscultation Valsalva maneuver reduced LV filling Standing—reduce venous return Squatting—increase venous return and systemic resistence Lying—increase venous return Hand grip—increase cardiac output and BP Amyl nitritevasodilationBP drop reflex tachycardiaincrease cardiac output Phenylephrine opposite effect of amyl nitite
Dynamic Auscultation
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Systolic Arterial Murmurs Normal anatomical arteries with normal or increased flow Abnormal arteries with tortuosity or luminal narrowing Systolic and crescendo-decrescendo configuration In old adults: atherosclerotic narrowing of a carotid, subclavian or iliofemeral artery A rare pulmonary arterial systolic murmur: by luminal narrowing after a pulmonary embolus
Supraclavicular Systolic Murmurs Often heard in children and aldolescents Originate at the aortic origins of normal major branchiocephalic arteries Crescendo-decrescendo, abrupt onset, loud and radiation below the clavicles Murmur decrease in response to hyperextension of the shoulders
Systolic Mammary Souffle Over the breast because of increase flow through normal arteries during late pregnancy or in lactating Begin after S1
Mid-Diastolic Murmurs Appreciable aortic valve incompetence or large left-to-right shunts, preceded by S3 Short, mid-diastolic aortic valve flow murmur in complete AV block Pulmonary valve regurgitation
Dynamic Auscultation Muller Maneuver Close the nose and seal the mouth then forcibly inspire for 10 seconds Widen the split S2 and augment murmurs originating in the right heart
Heart Murmur
Dynamic Ausculation Lesion Murmur Valsalva Hand Grip Squat Stand AS mid-systolic ↓ ↑ MR holosystolic VSD MVP Late systolic HOCM Amyl nitrite ↑ ↓
Heart Murmur Systolic murmur Early Systolic Murmuracute MR(giant V) TR with normal RV systolic pressure Midsystolic murmur(ejection murmur) AS, PS,VSD,ASD Late systolic murmurMVP Holosystolic murmur(regurgitant murmur) MR,TR(Carvallo sign selective inspiratory increase murmur),VSD