1. Wednesday November 30, 2005 Jason Ryan, MD
Residents Report
Wednesday November 30, 2005
Jason Ryan, MD

2. Valve Projection Areas

3. Cardiac Auscultation Murmurs Systolic
Ejection – Implies either obstruction or high output
Obstruction: AS, HOCM, rarely PS
High output: Anemia, Thyrotoxicosis, AR, ASD, VSD
Innocent murmur: Mid-systolic, best at LSB, non radiating
Pansystolic – Implies retrograde flow from high to low pressure chamber
MR, TR, VSD

4. Cardiac Auscultation Murmurs Diastolic
Retrograde flow across incompetent valve
AR, PR
Diastolic filling MS

5. The 6 “Must Know” Murmurs
Aortic Stenosis
HOCM
Mitral Regurgitation
Mitral Stenosis
Aortic Regurgitation
Tricuspid Regurgitation

6. Aortic Stenosis
Systolic ejection murmur that usually peaks in early systole
Location: Classically heard best in right 2nd interspace
As 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 carotids
Carotid upstrokes are delayed!
In reality, often loudest in a “sash” or “shoulder harness” area from second right interspace to apex

7. HOCM Caused by outflow tract obstruction
Location: 3rd or 4th left interspaces
Can sound just like AS unless you do maneuvers!
Increasing size of LV makes murmur softer
Squatting (raises BP)
Decreasing size of LV makes murmur louder
Valsalva (↑intrathoracic pres ↓VR↓LV)
Valsalva: HOCM gets louder, AS gets softer
Squatting: HOCM gets softer, AS gets louder

8. Mitral Regurgitation Holosystolic murmur
Location: Heard best at the apex
Radiates to the axilla
Pearl: Presence of S3 suggest severe MR
Bonus trivia: What is the Gallavardin phemonena?

9. Mitral Stenosis
Causes either (or both) an opening snap or a diastolic rumble.
Location: apex
More bonus (read: useless) trivia: What is the Austin Flint murmur?

10. Aortic Regurgitation Early diastolic murmur. “Blowing.”
Often associated with systolic ejection murmur from high stroke volume
Location: Heard best at LSB in 3rd or 4th IC space
Wide pulse pressure

11. Tricuspid Regurgitation
Holosystolic murmur
Causes: RV failure and dilation, Pulmonary hypertension of any cause
Location: Heard best at left lower sternal borderer
Clues:
Intensity may increase with inspiration
Look for large v waves in neck veins

12. Pearls PDA ASD VSD AV Dissociation MVP
Continuous, “machine-like” murmur
ASD
Fixed split S2
VSD
Usually a pansystolic murmur
AV Dissociation
Cannon AV waves, pounding in neck
MVP
Mid-systolic click
different from an opening snap which is diastolic

13. Pearls Normal heart sounds: S1 S2 S1 A2 P2
Inspiration causes “physiologic splitting”

14. Pearls Normal heart sounds:
A Right Bundle Branch Block delays P2 causing
a “widely split S2” which is a persistent split that
widens with inspiration: S1 A2 P2 S1 A2 P2

15. Pearls Normal heart sounds:
A Left Bundle Branch Block delays A2 causing
a “paradoxically (or reversed) split S2” which is
a split that occurs with expiration and disappears
with inspiration: S1 P2 A2 S1 S2

16. Question 1
1. 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 regurgitation
2. Aortic stenosis
3. Mitral regurgitation
4. Mitral stenosis

17. Answer 1
Aortic 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).

18. Question 2
A 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 regurgitation
2. Aortic stenosis
3. Mitral regurgitation
4. Mitral stenosis

19. Answer 2
Mitral 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.

20. Question 3
A 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 regurgitation
2. Aortic stenosis
3. Mitral regurgitation
4. Mitral stenosis

21. Answer 3
Mitral 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.

22. Question 4
During 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 stenosis
2. Dilated cardiomyopathy
3. Hypertrophic cardiomyopathy
4. Mitral regurgitation

23. Answer 4
Hypertrophic 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.

24. Question 5
During 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 defect
Ventricular septal defect
Aortic stenosis
Pulmonic stenosis

25. Answer 5
Atrial 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.

26. Question 6
A 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 contactions
2. Palpitations related to MVP
3. Paroxysmal SVT
4. Ventricular Tachycardia
5. Paroxysmal atrial flutter

27. Answer 6
Paroxysmal 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.

28. Question 7
A 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 stenosis
2. Congenitally abnormal pulmonary valve with moderate stenosis
3. Physiologic murmur related to pregnancy
4. Mitral valve regurgitation related to MVP
5. Bicuspid aortic valve with moderate regurgitation

29. Answer 7
Physiologic 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.

30. Question 8
A 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 stenosis
2. Mitral regurgitation related to MVP
3. VSD
4. Cardiomyopathy

31. Answer 8
VSD. 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.

32. Question 9
A 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 Stenosis
2. HOCM
3. Mitral Regurgitation
4. VSD

33. Answer 9
HOCM. 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 preloaddecreased LV size) is consistent with HOCM.

34. Welcome to the Applicants!
The End.