Assessment of Heart Murmurs

1
Assessment of Heart Murmurs

• Timing
• Location
• Characteristics
• Associated Illnesses/Symptoms
• Buzzwords
• Heart provides Tender Loving Care for Arterial
  Blood

2
General Principles

• Stenosis Harsh, turbulent flow
• Regurgitation softer, blowing, gurgle
• Systolic A/P stenosis, M/T regurg, VSD
• Diastolic A regurg or M stenosis

3
Mitral Regurgitation

• Defined Retrograde flow from the left ventricle
  through an incompetent mitral valve into the left
  atrium
• T- holosystolic
• L- apex, radiates to left axilla
• C- soft, high-pitched, blowing
• A- MV prolapse, MV myxomatous degeneration, MI,
  rheumatic heart disease, cardiomyopathy,
  endocarditis
• B- characteristics, location, radiation

4
Aortic Stenosis

• Defined Narrowing of the aortic outflow tract
  causing obstruction of flow from the left
  ventricle into the ascending aorta
• T- mid-systolic
• L- apex- R 2nd intercostal space, radiates to
  carotids
• C- harsh, loud, may have associated thrill,
  ejection click
• A- older age, bicuspid aortic valve, rheumatic
  fever
• B- age of patient, pulsus parvus et tardus,
  angina, syncope, heart failure

5
Possible Exam Question

• A 65-year-old man has had congestive heart
  failure with increasing pulmonary congestion and
  edema for several years. He has had increasing
  peripheral edema involving his lower legs in the
  last couple of days. His blood pressure is 125/85
  mm Hg. He is afebrile. He had been previously
  healthy all his life with no major illnesses. A
  serum glucose is 95 mg/dL. His total serum
  cholesterol is 185 mg/dL. The serum creatine
  kinase is not elevated. The most likely etiology
  for these findings is
• A. Alcoholic cardiomyopathy
• B. Calcified bicuspid aortic valve
• C. Tricuspid valve endocarditis
• D. Aortic dissection calcification
• E. Amyloidosis

6
Possible Exam Question

• A 65-year-old man has had congestive heart
  failure with increasing pulmonary congestion and
  edema for several years. He has had increasing
  peripheral edema involving his lower legs in the
  last couple of days. His blood pressure is 125/85
  mm Hg. He is afebrile. He had been previously
  healthy all his life with no major illnesses. A
  serum glucose is 95 mg/dL. His total serum
  cholesterol is 185 mg/dL. The serum creatine
  kinase is not elevated. The most likely etiology
  for these findings is
• A. Alcoholic cardiomyopathy
• B. Calcified bicuspid aortic valve
• C. Tricuspid valve endocarditis
• D. Aortic dissection calcification
• E. Amyloidosis

7
VSD

• Defined A congenital abnormality in which blood
  flows from high pressure LV? low pressure RV
  through a hole
• T- holosystolic
• L- 3rd, 4th, 5th left interspaces
• C- harsh, loud
• A- alone or with other abnormalities
• B- infant late cyanosis, holo/pancystolic
• adult progressive pulmonary HTN, Eisengengers
  syndrome

8
Possible Exam Question

• A term baby is sent home with his mother after
  delivery. The pregnancy was normal. No anomalies
  were noted at the time of birth. Five weeks
  later, the mother brings the baby to the clinic
  because the baby has difficulty breathing and
  occasionally turns blue. You hear a pansystolic
  murmur which is probably due to a(an)
• A. Hypertrophic subaortic stenosis
• B. Hypoplastic left heart syndrome
• C. Coarctation of the aorta
• D. Ventricular septal defect
• E. Bicuspid aortic valve

9
Possible Exam Question

• A term baby is sent home with his mother after
  delivery. The pregnancy was normal. No anomalies
  were noted at the time of birth. Five weeks
  later, the mother brings the baby to the clinic
  because the baby has difficulty breathing and
  occasionally turns blue. You hear a pansystolic
  murmur which is probably due to a(an)
• A. Hypertrophic subaortic stenosis
• B. Hypoplastic left heart syndrome
• C. Coarctation of the aorta
• D. Ventricular septal defect
• E. Bicuspid aortic valve

10
Possible Exam Question

• A 58-year-old man develops deep venous
  thrombosis during a hospitalization for
  prostatectomy. He exhibits decreased mental
  status with right hemiplegia, and a CT scan of
  the head suggests an acute cerebral infarction in
  the distribution of the left middle cerebral
  artery. A chest radiograph reveals cardiac
  enlargement and prominence of the main pulmonary
  arteries that suggests pulmonary hypertension.
  His serum troponin I is lt0.4 ng/mL. Which of the
  following lesions is most likely to be present on
  echocardiography
• A. Coarctation of the aorta
• B. Tetralogy of Fallot
• C. Ventricular septal defect
• D. Pulmonic stenosis
• E. Dextrocardia

11
Possible Exam Question

• A 58-year-old man develops deep venous
  thrombosis during a hospitalization for
  prostatectomy. He exhibits decreased mental
  status with right hemiplegia, and a CT scan of
  the head suggests an acute cerebral infarction in
  the distribution of the left middle cerebral
  artery. A chest radiograph reveals cardiac
  enlargement and prominence of the main pulmonary
  arteries that suggests pulmonary hypertension.
  His serum troponin I is lt0.4 ng/mL. Which of the
  following lesions is most likely to be present on
  echocardiography
• A. Coarctation of the aorta
• B. Tetralogy of Fallot
• C. Ventricular septal defect
• D. Pulmonic stenosis
• E. Dextrocardia

12
Mitral Prolapse

• Defined A bulging of one or both mitral valve
  leaflets into the left atrium during systole
• T- late systolic
• L- apex
• C- midsystolic click
• A- 5 normal population, asymptomatic, sudden
  death
• B- midsystolic click, most common valvular
  lesion, balloning/floppy valve, Marfans syndrome

13
Possible Exam Question

• A 19-year-old woman is found to have a cardiac
  murmur characterized by a mid systolic click. An
  echocardiogram demonstrates mitral insufficiency
  with upward displacement of one leaflet. There is
  aortic root dilation to 4 cm. She has a
  dislocated right ocular crystalline lens. She
  dies suddenly and unexpectedly. The medical
  examiner finds a prolapsed mitral valve with
  elongation, thinning, and rupture of chordae
  tendineae. A mutation involving which of the
  following genes is most likely to be present in
  this patient
• Beta-myosin
• CFTR
• FGFR
• Fibrillin
• Spectrin

14
Possible Exam Question

• A 19-year-old woman is found to have a cardiac
  murmur characterized by a mid systolic click. An
  echocardiogram demonstrates mitral insufficiency
  with upward displacement of one leaflet. There is
  aortic root dilation to 4 cm. She has a
  dislocated right ocular crystalline lens. She
  dies suddenly and unexpectedly. The medical
  examiner finds a prolapsed mitral valve with
  elongation, thinning, and rupture of chordae
  tendineae. A mutation involving which of the
  following genes is most likely to be present in
  this patient
• Beta-myosin
• CFTR
• FGFR
• Fibrillin
• Spectrin

15
Aortic Regurgitation

• Defined Retrograde flow from the aorta into the
  left ventricle through incompetent aortic cusps
• T- Diastolic
• L- 2nd-4th left interspaces
• C- high-pitched, blowing
• A- aortic root degeneration, rheumatic heart
  disease, VSD w/aortic valve prolapse (kids)
• B- high pulse pressure bounding pulses

16
Possible Exam Question

• A 67-year-old man presents to his doctors
  office for an insurance physical. During blood
  pressure measurement, the nurse notes that
  systolic sounds are heard with the cuff
  completely deflated. The blood pressure is
  180/60 mm Hg. Physical examination reveals
  bounding pulses and a high-pitched, blowing
  diastolic murmur, heard best along the left
  sternal border. Which of the following are the
  most likely diagnosis?
• A. Aortic regurgitation
• Aortic valve obstruction
• Cardiac Tamponade
• Heart failure
• Hypovolemia

17
Possible Exam Question

• A 67-year-old man presents to his doctors
  office for an insurance physical. During blood
  pressure measurement, the nurse notes that
  systolic sounds are heard with the cuff
  completely deflated. The blood pressure is
  180/60 mm Hg. Physical examination reveals
  bounding pulses and a high-pitched, blowing
  diastolic murmur, heard best along the left
  sternal border. Which of the following are the
  most likely diagnosis?
• A. Aortic regurgitation
• Aortic valve obstruction
• Cardiac Tamponade
• Heart failure
• Hypovolemia

18
Mitral Stenosis

• Defined Obstruction of flow from left atrium to
  left ventricle because of a narrowed mitral
  orifice
• T- Diastolic
• L- Apex
• C- opening snap, low pitched
• A- Rheumatic fever
• B- hx of childhood rheumatic fever presents with
  progressive dyspnea, pulmonary edema, hempotysis

19
Possible Exam Question

• A 30 year-old Hispanic woman reports to her
  primary care physician complaining of progressive
  dyspnea. She reports she has a two-year history
  of exertional shortness of breath that has now
  worsened and affects her even with modest amounts
  of activity. Occasionally, a dry cough
  accompanies her dyspnea. Today, she had a mild
  episode of hemoptysis, which prompted her visit.
  She denies fever, chills, or sputum production.
  Her medical history is significant for a febrile
  illness with sore throat and joint pain at the
  age of 15 in Mexico. On examination, she is a
  well-developed female in no acute distress. A
  crescendo diastolic rumble is present at the apex
  of the heart and fine crackles are auscultated at
  the lung bases. Which of the following is the
  most likely diagnosis?
• Mitral stenosis
• Myocardial infarcion
• Pneumonia
• Pulmonary effusion
• Pulmonary embolus

20
Possible Exam Question

• A 30 year-old Hispanic woman reports to her
  primary care physician complaining of progressive
  dyspnea. She reports she has a two-year history
  of exertional shortness of breath that has now
  worsened and affects her even with modest amounts
  of activity. Occasionally, a dry cough
  accompanies her dyspnea. Today, she had a mild
  episode of hemoptysis, which prompted her visit.
  She denies fever, chills, or sputum production.
  Her medical history is significant for a febrile
  illness with sore throat and joint pain at the
  age of 15 in Mexico. On examination, she is a
  well-developed female in no acute distress. A
  crescendo diastolic rumble is present at the apex
  of the heart and fine crackles are auscultated at
  the lung bases. Which of the following is the
  most likely diagnosis?
• Mitral stenosis
• Myocardial infarcion
• Pneumonia
• Pulmonary effusion
• Pulmonary embolus

21
Patent Ductus Arteriosus

• Defined Failure of the duct between pulmonary
  artery and aorta to close
• T- Continuous
• L- upper left sternal border
• C- machine-like
• A- left ? right shunt, cyanosis
• B- infants, machine-like, continuous murmur

22
Possible Exam Question

• An x-ray performed on a newborn infant shows
  enlargement of the left ventricle and left atrium
  as well as dilation of the aorta.
  Echocardiographic studies demonstrate
  volume-overloading of the left ventricle.
  Cardiac auscultation reveals the presence of a
  continuous, machine-like murmur. Which of the
  following is the most likely diagnosis?
•  
• Atrial septal defect
• Patent ductus arteriosus
• Pulmonic stenosis
• Tetralogy of Fallot
• Ventricular septal defect

23
Possible Exam Question

• An x-ray performed on a newborn infant shows
  enlargement of the left ventricle and left atrium
  as well as dilation of the aorta.
  Echocardiographic studies demonstrate
  volume-overloading of the left ventricle.
  Cardiac auscultation reveals the presence of a
  continuous murmur. Which of the following is the
  most likely diagnosis? 
• Atrial septal defect
• Patent ductus arteriosus
• Pulmonic stenosis
• Tetralogy of Fallot
• Ventricular septal defect

24
Bonus Question

• The infants murmur is most likely related to
  which of the following
• Blood flowing across the aortic valve
• Blood flowing from the aorta to the pulmonary
  artery
• Blood flowing from the left ventricle to the
  right ventricle
• Blood flowing from the pulmonary artery to the
  aorta
• Blood flowing from the right ventricle to the
  left ventricle

25
Bonus Question

• The infants murmur is most likely related to
  which of the following
• Blood flowing across the aortic valve
• Blood flowing from the aorta to the pulmonary
  artery
• Blood flowing from the left ventricle to the
  right ventricle
• Blood flowing from the pulmonary artery to the
  aorta
• Blood flowing from the right ventricle to the
  left ventricle

26
Congestive Heart Failure

• Cause ? Effect
• LV output does not ? w/exercise ? DOE
• ? End Diastolic Volume ? Cardiac Dilation
• LV failure ? ? pulmonary venous pressure ? fluid
  transudation ? Pulmonary Edema, PND
• ? venous return exacerbates pulmonary vascular
  congestion ? Orthopnea

27
Congestive Heart Failure

• ? central venous pressure ? ? resistance to
  portal flow? Hepatomegaly (nutmeg liver)
• RV failure ? ? venous pressure ? fluid
  transudation? Ankle, sacral edema

28
Cardiac Tumors

• Most common tumor Metastasis
• I
• Most common 1 adult tumor Myxoma
• Ball-valve obstruction in Left Atrium (LA
• Dodgers)
• Most common 1 pediatric tumor rhabdomyoma
• Associated with tuberous sclerosis

29
Possible Exam Question

• An adult presents to a physician because of
  repeated episodes of fainting. ECG fails to
  disclose and arrhythmia. Echocardiogram shows a
  mass in the left atrium that is producing
  intermittent obstruction of flow. Which of the
  following would most likely be seen on
  microscopic examination of the resected mass?
•  
• Benign myxoid tumor
• Benign tumor with gland formation
• Benign tumor with striated muscle differentiation
• Malignant tumor with gland formation
• Malignant tumor with striated muscle
  differentiation

30
Possible Exam Question

• An adult presents to a physician because of
  repeated episodes of fainting. ECG fails to
  disclose and arrhythmia. Echocardiogram shows a
  mass in the left atrium that is producing
  intermittent obstruction of flow. Which of the
  following would most likely be seen on
  microscopic examination of the resected mass?
•  
• Benign myxoid tumor
• Benign tumor with gland formation
• Benign tumor with striated muscle differentiation
• Malignant tumor with gland formation
• Malignant tumor with striated muscle
  differentiation

31
Embolus Types
Today the vasculature, tomorrow the world!

• Fat- long bone fractures and liposuction
• Air
• Thrombus
• Bacteria
• Amniotic Fluid ? postpartum DIC
• Tumor

32
Cardiac Tamponade

• Tamponade closure or blockage (as of a wound or
  body cavity)
• Tampon stops fluid flow
• Compression of heart by fluid in the pericardium
  ? ? CO, pressure equilibration
• PE hypotension, JVD (? venous pressure), heart
  sounds distant or muffled
• Other findings electrical alternans of EKG,
  pulsus paradoxus (variation with respiration)

33
Deep Venous Thrombosis

• Virchow Virtuous Cow
• Holy Trinity
• Stasis
• Hypercoagulability
• Endothelial Damage

34
Bacterial Endocarditis

• Meet Tarzan and Jane
• For Tarzan, love at first sight (rapid onset)
• Jane is a golden girl (S. aureus)
• Would like to take her into the vegetation and
  get to know her better

35
Bacterial Endocarditis

• Jane is not nice to Tarzan
• Thinks Tarzan is not too bright, doesnt have
  good hygiene (green teeth viridans
  streptococcus)
• Ends up breaking his heart (chordae rupture,
  supporative pericarditis)
• Tarzan feels unmitigated despair (mitral valve)

36
Bacterial Endocarditis

• Fever
• Roths spots
• Oslers nodes
• Murmur
• Janeway lesions
• Anemia
• Nail-bed hemorrhages
• Emboli

• It gets so bad, Tarzan eventually turns to IV
  drugs
• Ends up with getting endocarditis in his
  tricuspid valve

37
Non-Infectious Endocarditis

• 2 to metastasis or renal failure
  (marantic/thrombotic endocarditis)
• Libman-Sacks endocarditis
• vegetations on both sides of valve ? mitral valve
  stenosis do not embolize
• Associated with lupus SLE causes LSE

"What is it? Meningitis? Scoliosis?? Lupus??? Is
it Lupus????"
38
Possible Exam Question

• A 27-year-old man has become severely ill over
  the past three days, with fever and malaise. On
  admission to the emergency room, he has a heart
  rate of 105/minute, respiratory rate of 24, blood
  pressure of 80/40 mm Hg, and temperature 39.1 C.
  A grade IV/VI diastolic murmur is audible. He has
  small hemorrhages visible on nail beds. His
  spleen tip is palpable. The process that is LEAST
  likely to predispose this illness is
• Ventricular septal defect
• Rheumatic heart disease
• Cardiac amyloidosis
• Intravenous drug use
• Prosthetic valve placement

39
Possible Exam Question

• A 27-year-old man has become severely ill over
  the past three days, with fever and malaise. On
  admission to the emergency room, he has a heart
  rate of 105/minute, respiratory rate of 24, blood
  pressure of 80/40 mm Hg, and temperature 39.1 C.
  A grade IV/VI diastolic murmur is audible. He has
  small hemorrhages visible on nail beds. His
  spleen tip is palpable. The process that is LEAST
  likely to predispose this illness is
• Ventricular septal defect
• Rheumatic heart disease
• Cardiac amyloidosis
• Intravenous drug use
• Prosthetic valve placement

40
Rheumatic Fever

• Consequence of infection with group A b-hemolytic
  streptococci
• Late sequelae includes valvular disease (Romantic
  Fever)
• I M.A.T.
• Mitral gt Aortic gt Tricuspid

41
Rheumatic Fever

• Fever
• Erythema marginatum
• Valvular damage
• ESR ?
• Red-hot joints (polyarthritis)
• Subcutaneous nodules
• St. Vitus Dance (chorea)
• Strep antibody titer (ASO ?)

• Aschoff Bodies
• Granulomas with giant cells
• Anitschkows cells
• Activated histiocytes
• Two RHussians with RHumatic heart disease

42
Rheumatic Fever

• John Travolta career slump
• Makes sequel to Saturday Night Fever called
  Rheumatic Fever
• John gets
• Fever
• Myocarditis
• Joint swelling (Polyarthritis)
• Chorea (uncontrolled dance-like movements of
  extremities

St. Vitus Dance
43
Possible Exam Question

• A 42-year-old woman has increasing congestive
  heart failure. As a child she suffered recurrent
  bouts of pharyngitis with group A beta hemolytic
  streptococcal infections. The cardiac valves most
  likely to be affected are
• Aortic and tricuspid
• Mitral and pulmonic
• Aortic and pulmonic
• Tricuspid and pulmonic
• Mitral and aortic

44
Possible Exam Question

• A 42-year-old woman has increasing congestive
  heart failure. As a child she suffered recurrent
  bouts of pharyngitis with group A beta hemolytic
  streptococcal infections. The cardiac valves most
  likely to be affected are
• Aortic and tricuspid
• Mitral and pulmonic
• Aortic and pulmonic
• Tricuspid and pulmonic
• Mitral and aortic

45
Pericarditis

• Serous
• SLE,
• Rhuematoid arthritis
• Uremia
• Infection (serious)
• Fibrinous
• MI (death of muscle fibers)
• Rhuematic fever
• Uremia

• Hemorrhagic (Invasive!)
• TB (think hemoptysis)
• Malignancy (aggressive)
• May resolve without scarring
• May progress to chronic adhesive or constrictive
  pericarditis

46
Syphilitic Heart Disease

• 3 syphillis- long standing
• Destruction of vasa vasorum
• Dilation of aortic root without atherosclerotic
  lesion syphilitic aneurysm
• Calcification of ascending arch and aortic root
• Tree-barking- post-inflammatory scarring of the
  aorta

47
Possible Exam Question

• Examination of an autopsy specimen from a
  Mexican immigrant demonstrates a heart with
  massive dilation of the aortic root and adjacent
  aortic arch. Opening the aorta reveals a
  distinctive wrinkling of the intimal surface. If
  a histological section through the aortic wall is
  made, which of the following will be seen?
• A heavy eosinophilic infiltrate
• Fibrinoid necrosis with a neutrophilic
  infiltration
• Focal fragmentation of elastic elements
• Obliterative endarteritis of vasa vasorum
• Ring-like calcification of the vessel media

48
Possible Exam Question

• Examination of an autopsy specimen from a
  Mexican immigrant demonstrates a heart with
  massive dilation of the aortic root and adjacent
  aortic arch. Opening the aorta reveals a
  distinctive wrinkling of the intimal surface. If
  a histological section through the aortic wall is
  made, which of the following will be seen?
• A heavy eosinophilic infiltrate
• Fibrinoid necrosis with a neutrophilic
  infiltration
• Focal fragmentation of elastic elements
• Obliterative endarteritis of vasa vasorum
• Ring-like calcification of the vessel media

49
Thromboangitis Obliterans Buergers Disease
If only I had hands, I would eat a Buerger!

• Idiopathic, associated with smoking
• Segmental, thrombosing vasculitis of small-medium
  peripheral arteries and veins
• Symptoms claudication, cold sensitivity
  (Raynauds phenomenon), severe pain, gangrene
• Symptoms may improve if patient quits smoking

50
Takayasus Arteritis

• Pulseless disease
• Granulomatous thickening of aortic arch and
  proximal great veins
• Associated with ? ESR
• Primarily affects Asian females lt40
• FAN MY SKIN On Wednesday

51
Takayasus Arteritis

• Fever
• Arthritis
• Night sweats
• MYalgia
• SKIN nodules
• Ocular disturbances
• Weak pulse in upper extremity

52
Temporal Arteritis (Giant Cell Arteritis)

• Medium and small arteries, usually branches of
  carotid artery (temporal artery)
• Giant cells
• Presentation older female, unilateral headache,
  jaw claudication, impaired vision
• Blindness is possible complication
• Responds to steroids
• Elevated ESR

53
Possible Exam Question

• A 74-year-old woman has had increasingly severe,
  throbbing headaches for several months, centered
  on the right. She sees her physician, who records
  vital signs of T 36.1 R 22 P 82 and BP 130/85 mm
  Hg. There is a palpable tender cord-like area
  over her right temple. Her heart rate is regular
  with no murmurs, gallops, or rubs. Pulses are
  equal and full in all extremities. A biopsy of
  this lesion is obtained next, and histologic
  examination reveals a muscular artery with
  lumenal narrowing and medial inflammation with
  lymphocytes, macrophages, and occasional giant
  cells. She improves with a course of high-dose
  corticosteroid therapy. Which of the following
  laboratory test findings is most likely to be
  present with this disease
• Erythrocyte sedimentation rate of 110 mm/hr
• Rheumatoid factor titer of 80 IU/mL
• HDL cholesterol of 15 mg/dL
• Anti-double stranded DNA titer of 11024
• pANCA titer of 1160

54
Possible Exam Question

• A 74-year-old woman has had increasingly severe,
  throbbing headaches for several months, centered
  on the right. She sees her physician, who records
  vital signs of T 36.1 R 22 P 82 and BP 130/85 mm
  Hg. There is a palpable tender cord-like area
  over her right temple. Her heart rate is regular
  with no murmurs, gallops, or rubs. Pulses are
  equal and full in all extremities. A biopsy of
  this lesion is obtained next, and histologic
  examination reveals a muscular artery with
  lumenal narrowing and medial inflammation with
  lymphocytes, macrophages, and occasional giant
  cells. She improves with a course of high-dose
  corticosteroid therapy. Which of the following
  laboratory test findings is most likely to be
  present with this disease
• Erythrocyte sedimentation rate of 110 mm/hr
• Rheumatoid factor titer of 80 IU/mL
• HDL cholesterol of 15 mg/dL
• Anti-double stranded DNA titer of 11024
• pANCA titer of 1160

55
Questions?