Transcript Adult Heart Murmurs

Adult Heart Murmurs
Or, Between the Lubs and the Dubs
Paul D. Simmons, MD, FAAFP
Faculty Physician
St. Mary’s Family Medicine Residency Program
Grand Junction, Colorado
Learning Objectives
At the end of this presentation, you should be able to:
1. Distinguish innocent and abnormal heart murmurs in patients and
classify them as systolic, diastolic or continuous.
2. Formulate a differential diagnosis of specific cardiac sounds and
explain the pathology of heart murmurs to patients.
3. Evaluate diagnostic factors in patients with suspected heart
murmurs using cost-effective cardiac testing.
Question 1
Who invented the stethoscope?
A. William Osler
B. Robert Koch
C. Rene Laennec
D. Edward Jenner
E. Moses Maimonides
Question 2
Which of the following murmurs would be heard during diastole?
A. Aortic stenosis (AS)
B. Pulmonic stenosis (PS)
C. Tricuspid regurgitation (TR)
D. Mitral stenosis (MS)
E. Mitral regurgitation (MR)
Question 3
You are examining a 30 year old woman, a new patient to your practice.
You do not have medical records for her yet, but she states she has no
history of a murmur. On auscultation, you hear a murmur. Which of the
following would NOT be suggestive of a benign, functional murmur?
A. Systolic murmur of short duration (i.e., not holosystolic)
B. Intensity less than or equal to 2/6
C. Early to mid-systolic
D. Decreased intensity when the patient stands or Valsalvas
E. Diastolic murmur
Why Should We Care?
“Auscultation has a reported sensitivity of 70% and a specificity of
98% for detection of valvular heart disease.”
Orient JM (2010). Sapira’s Art & Science of Bedside Diagnosis, 4th edition. Philadelphia, PA: Wolters Kluwer Health.
Image public domain, copyright
expired, WikiCommons
Image from
Wikicommons
user CFCF,
Creative
Commons
AS / PS
MR / TR
MVP
Image from
Wikicommons
user CFCF,
Creative
Commons
AR / PR
MS / TS
Image from
Wikicommons
user CFCF,
Creative
Commons
Another Way to Remember
Valve
Stenosis
Regurgitation
Aortic
Systolic “Manly”
Diastolic
HOOOT Dub
Lub hoot
Systolic “Manly”
Diastolic
HOOOT Dub
Lub hoot
Diastolic
Systolic “Blowing”
Lub hoot
Hoot Dub
Diastolic
Systolic “Blowing”
Lub hoot
Hoot Dub
Pulmonic
Tricuspid
Mitral
Valve
Stenosis
Regurgitation
Aortic
Systolic “Manly”
Diastolic
HOOOT Dub
Heard at A,  carotid
Lub hoot
Systolic “Manly”
Diastolic
HOOOT Dub
Heard at P, no  carotid
Lub hoot
Diastolic
Systolic “Blowing”
Lub hoot
Holosystolic, T area, no rad
Hoot Dub
Diastolic
Systolic “Blowing”
Lub hoot
Holosystolic, M area,  axilla
Hoot Dub
Pulmonic
Tricuspid
Mitral
Valve
Stenosis
Regurgitation
Aortic
Systolic “Manly”
Diastolic
HOOOT Dub
Heard at A,  carotid
Lub hoot
Heard at LLSB, decrescendo
Systolic “Manly”
Diastolic
HOOOT Dub
Heard at P, no  carotid
Lub hoot
Heard at LUSB, decrescendo
Diastolic
Systolic “Blowing”
Pulmonic
Tricuspid
Lub K-hoot
Hooot Dub
Opening snap, heard at T area, Holosystolic, T area, no 
presystolic “rumble”
Mitral
Diastolic
Systolic “Blowing”
Lub K-hoot
Opening snap, heard at M
area, presystolic “rumble”
Hooot Dub
Holosystolic, M area,  axilla
Phonocardiograms
AS may have ejection “click” at
onset of murmur
A “continuous” murmur…
Image from Wikicommons user
Madhero88, creative commons
license
Systolic Murmur Pathophysiology
Flow across an obstruction: AS, PS or idiopathic hypertrophic
subaortic stenosis
Increased flow across a normal valve: ASD – not from flow across the
defect, but rather from increased ejection volume
Regurgitation from high pressure to low pressure: MR, TR or VSD
Diastolic Murmur Pathophysiology
Generally, diastolic murmurs are softer and lower pitch because of
lower pressure during diastole
Regurgitant flow across an aortic or pulmonic (semilunar) valve
Abnormal flow across tricuspid or mitral valves, or “rumble” from
increased volume across a normal A-V valve
How Good Are Murmurs at Detecting Valve Disease?
From McGee
S. (2012), p.
361
“Typical” murmur
+ LR
- LR
Aortic stenosis
5.9
0.1
Sev aortic stenosis
3.6
0.06
Mitral regurg
5.4
0.3
Tricuspid regurg
14.6
VSD
24.9
MVP
12.1
AR
9.9
PR
17.4
0.3
Maneuvers and Murmurs
Inspiration: decreases intrathoracic pressure, increases venous return
to the R heart, and thus increasing TR murmur (Carvallo sign)
Valsalva: increases intrathoracic pressure, decreases venous return to
the heart, decreases MVP murmur due to decreased afterload
Squat-to-stand: decreased venous return, moving mitral leaflet closer
to the septum, and increases IHSS murmur and MVP murmur
Stand-to-squat: increases venous return, so softens IHSS murmur
Continuous Murmurs
- “Continuous” murmurs aren’t necessarily continuous, but they don’t
obey systolic / diastolic boundaries.
- Partial DDx of continuous murmurs:
note that most of these are external to the heart itself
-
Patent ductus arteriosus
L to R shunt from ASD
A-V fistula
Coarctation of the aorta
Partial obstruction of the pulmonary artery by PE
Venous hum
“Mammary souffle” of pregnancy
Question 4
You are seeing a 62 year old man with an apparently new systolic
murmur. Which of the following would NOT be an indication for
immediate echocardiography?
A. Systolic murmur with new chest pain and dyspnea
B. Asymptomatic patient with a 2/6 systolic murmur
C. Asymptomatic patient with a 4/6 systolic murmur
D. Asymptomatic patient with a 2/6 systolic murmur and decreased
carotid upstroke
E. All of the above are indications for echocardiography
When to Get an Echo
• Any murmur with cardiac
symptoms
• Asymptomatic patients with a
diastolic murmur
• Asymptomatic with a loud
(3+/6) systolic murmur
• Systolic murmur with other
abnormal cardiovascular
findings (e.g., systolic click,
decreased carotid upstroke)
Figure 3 from Shipton B, Wahba H.
(2001), AFP 63 (11): 2201 ff.
From Choosing Wisely: Cardiology
Don’t perform echocardiography as routine follow-up for mild,
asymptomatic native valve disease in adult patients with no
change in signs or symptoms.
http://www.choosingwisely.org/doctor-patient-lists/american-college-of-cardiology/
Question 5
You are examining a 72 year old woman with a history of COPD,
ischemic and hypertensive cardiomyopathy, and DVT without PE. You
hear an extra heart sound beyond S1 and S2. Which of the following
statements is TRUE?
A. S3 and S4 are best heard with the patient supine while holding a
deep breath.
B. S3 is caused by the atrial jet hitting a volume-overloaded ventricle.
C. S4 is caused by sudden tensing of mitral valve chordae tendinae.
D. S3 is always abnormal.
E. All of the above are true.
Some Pearls About S3 and S4
• S3 and S4 are heard best in the L lateral decubitus position, and both
are more “felt” with the eardrums than heard – very low frequency
• S3 is caused by atrial filling into a volume overloaded ventricle
• S4 is caused by atrial jet hitting a stiff, hypertrophic ventricle
(pressure overload)
• S3 can be normal in children
Excellent Physical Exam Resources
McGee S. (2012). Evidence-Based Physical Diagnosis, 3rd edition.
Orient JM. (2010). Sapira’s Art & Science of Bedside Diagnosis, 4th edition.
Stanford Medicine 25 Website: stanfordmedicine25.stanford.edu
Heart Sounds & Murmurs app (Android)
Heart Murmur Pro (iOS, $2.99)
References
Orient JM. (2010). Sapira’s Art & Science of Bedside Diagnosis, 4th ed. Philadelphia, PA: Wolters Kluwer Health.
McGee S. (2012). Evidence-Based Physical Diagnosis, 3rd ed. (Chapter 41 – Heart Murmurs, General Principles,
p. 351ff.)
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ,
Sorayja P, Sundt TM 3rd, Thomas JD. (2014). AHA/ACC Guideline for the management of patients with valvular
heart disease: A report of the American College of Cardiology / American Heart Association task force on practice
guidelines. J Am Coll Cardiol 2014; 63(22):e57ff.
Mineo K, Cummings J, Josephson R, Nanda NC. (2001). Acquired left ventricular outflow tract obstruction during
acute myocardial infarction: Diagnosis of a new cardiac murmur. Am J Geriatr Cardiol., 10(5): 283-5.
Thank you!
Email: [email protected]
Twitter: @pauldsimmons