Assessment of Heart Murmurs

Timing Location Characteristics Associated Illnesses/Symptoms Buzzwords

Heart provides Tender Loving Care for Arterial Blood

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

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

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

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

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

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

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

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

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 <0.4 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

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 <0.4 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

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

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

A. B. C. D. E.

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

A. B. C. D. E.

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

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 B. Aortic valve obstruction C. Cardiac Tamponade D. Heart failure E. Hypovolemia

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 highpitched, blowing diastolic murmur, heard best along the left sternal border. Which of the following are the most likely diagnosis? A. Aortic regurgitation B. Aortic valve obstruction C. Cardiac Tamponade D. Heart failure E. Hypovolemia

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

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

A. B. C. D. E.

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

A. B. C. D. E.

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

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? A. B. C. D. E. Atrial septal defect Patent ductus arteriosus Pulmonic stenosis Tetralogy of Fallot Ventricular septal defect

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

A. B. C. D. E.

Bonus Question
A. B. C. D. E. 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

Bonus Question
A. B. C. D. E. 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

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

Congestive Heart Failure

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

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

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? A. B. C. D. E. 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

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? A. B. C. D. E. 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

Embolus Types
Today the vasculature, tomorrow the world!

Fat- long bone fractures

and liposuction

Air Thrombus Bacteria Amniotic Fluid

postpartum DIC

Tumor

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)

Deep Venous Thrombosis

Virchow = Virtuous Cow Holy Trinity: Stasis Hypercoagulability Endothelial Damage

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

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)

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

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????"

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

A. B. C. D. E.

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

A. B. C. D. E.

Rheumatic Fever
Consequence of infection with group A bhemolytic streptococci Late sequelae includes valvular disease (Romantic Fever):

M.A.T.
Mitral > Aortic > Tricuspid

Rheumatic Fever

Aschoff Bodies Fever Granulomas with Erythema marginatum giant cells Valvular damage Anitschkows cells Activated ESR histiocytes Red-hot joints (polyarthritis) Two RHussians Subcutaneous nodules with RHumatic St. Vitus Dance (chorea) heart disease Strep antibody titer (ASO )

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

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

A. B. C. D. E.

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

A. B. C. D. E.

Pericarditis
Serous
SLE, Rhuematoid arthritis Uremia Infection (serious)

Hemorrhagic (Invasive!)
TB (think hemoptysis) Malignancy (aggressive)

Fibrinous
MI (death of muscle fibers) Rhuematic fever Uremia

May resolve without scarring May progress to chronic adhesive or constrictive pericarditis

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- postinflammatory scarring of the aorta

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

A. B. C. D. E.

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

A. B. C. D. E.

If only I had hands, I would eat a Buerger!

Thromboangitis Obliterans: Buergers Disease

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

Takayasus Arteritis
Pulseless disease Granulomatous thickening of aortic arch and proximal great veins Associated with ESR Primarily affects Asian females <40 FAN MY SKIN On Wednesday

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

 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

Temporal Arteritis (Giant Cell Arteritis)

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 1:1024 pANCA titer of 1:160

A. B. C. D. E.

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 1:1024 pANCA titer of 1:160

A. B. C. D. E.

Questions?