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Residents Report Wednesday November 30, 2005 Jason Ryan, MD Valve Projection Areas 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 Cardiac Auscultation Murmurs – Diastolic Retrograde flow across incompetent valve – AR, PR Diastolic filling – MS The 6 “Must Know” Murmurs 1. Aortic Stenosis 2. HOCM 3. Mitral Regurgitation 4. Mitral Stenosis 5. Aortic Regurgitation 6. Tricuspid Regurgitation 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 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 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? 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? 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 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 Pearls PDA – 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 Pearls Normal heart sounds: S1 S2 S1 A2 P2 Inspiration causes “physiologic splitting” Pearls Normal heart sounds: S1 S2 S1 A2 P2 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 Pearls Normal heart sounds: S1 S2 S1 A2 P2 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 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 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). 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 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. 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 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. 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 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. Question 5 During a routine physical examination of a 15year-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 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. 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 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. 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 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. 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 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. 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 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 preloaddecreased LV size) is consistent with HOCM. Welcome to the Applicants! The End.