PowerPoint Presentation

Heart MurmursAvaneesh Jakkoju, MD

Why is a murmur important

High yield on boardsUnderstanding the physiology of heartKnow when to reassure and when to further investigateImportant murmurs are easy to missLook cool in front of your peers

Systolic vs. DiastolicSystole MR, TR, AS, HOCM

Diastole AI, MS

Continuous PDA

We are only covering high yield topics for boards, this list does not cover all the murmurs

Mitral regurgitationHolosystolic murmurLocation: ApexQuality: blowing high pitchedRadiation: to axillaCould be end systolic in case of MVP

Mitral regurgitation

Source:http://www.texasheart.org/Education/CME/explore/events/HSPS07_mitral_regurg.cfmSource: http://www.med.umich.edu/lrc/psb_open/html/repo/primer_heartsound/primer_heartsound.html

Mitral stenosisDiastolic rumbleApexSevere disease- holodiastolicLoud S1, opening snap and soft S2

Mitral stenosis

Source: http://www.cvphysiology.com/Heart%20Disease/HD004.htmSource: http://www.med.umich.edu/lrc/psb_open/html/repo/primer_heartsound/primer_heartsound.html

Aortic stenosisHarsh Crescendo-decrescendo mid systolic murmurRight upper sternal borderRadiates to carotidsSigns of severe disease:Decrease/soft S2 or single S2Pulsus parvus et tardus Late peaking in systole and prolonged murmur

Aortic stenosis

Aortic insufficiencyBlowing diastolic murmur heard at the Left Upper sternal borderBest heard when sitting or leaning forwardWidened pulse pressure seen in chronic but not in acuteAcute setting caused by aortic dissection involving the rootDecreased S1 and S2 (A2)Duration correlates with severity; pan-diastolic when very severe

Aortic insufficiency

Tricuspid regurgitationHolosystolic murmur heard at left lower sternal border; may even be present at apex if severe RV hypertrophyLoudness depends on degree of pulmonary hypertensionPulsatile jugular vein on exam, dynamic right ventricular heave due to the dilated right ventriclePatients are often asymptomatic or murmur is hard to appreciateMost often diagnosed on Echocardiography than auscultation

HOCMHarsh midsystolic crescendo-decrescendo murmur at left sternal borderDifferentiate from AS by location (AS best heard at RUSP)Either no radiation or radiation to axilla (AS to carotids)Brisk carotid pulse (AS weak pulse)

Its the asymmetry of the septal hypertrophy that causes outflow tract obstruction. If there is symmetric hypertrophy of the left ventricle due to long standing hypertrophy septum wont be pressing against anterior leaflet of mitral valve during systole. Outflow obstruction is flow dependent.14

Physiologic vs. pathologic murmursBenign murmurs are midsystolic Never louder than 1-2/6, never diastolicNever radiate to carotids, do not improve with valsalvaChildren or young adults they are due to vibrations across the pulmonary valve leaflets or pulmonary trunk, heard at LLSB or precordium- stills murmurBenign murmur in older patient is usually due to Aortic valve sclerosis

What happens with different maneuvers?Murmurs increase in frequency when flow across the valve increases exceptHOCM where increased ventricular volume relieves outflow tract obstruction

Source: http://knowmedge.com/blog/internal-medicine-board-review-cardiac-murmurs/

Source: https://en.wikipedia.org/wiki/Heart_murmur#/media/File:Phonocardiograms_ from_ normal_and_abnormal_heart_sounds.png

Lilly, L. & Jung, H. (2011a). Locations of maximum intensity of common murmurs [Image]. In L. Lilly (Ed.), Pathyphysiology of Heart Disease. (5th ed.). Baltimore, Maryland: Lippincott Williams & Wilkins.

Apex, Holo Sys Mur, Supine, BellApexUniversity of Michigan Heart Sound and Murmur Library, track 9/23200760237.223eng - Produced by The Learning Resource Center - Office of Medical Education copyright 2007 The Regents Of The University Of Michigan. All rights reserved.eng - iTunPGAP0eng - iTunNORM 00000030 00000000 000000F1 00000000 0000B4D0 00000000 00003224 00000000 00000FB6 00000000eng - iTunSMPB 00000000 00000210 00000874 0000000000287E7C 00000000 000EA7D7 00000000 00000000 00000000 00000000 00000000 00000000Apex, OS & Dias Mur, LLD, BellApexUniversity of Michigan Heart Sound and Murmur Library, track 13/23200761177.582eng - Produced by The Learning Resource Center - Office of Medical Education copyright 2007 The Regents Of The University Of Michigan. All rights reserved.eng - iTunPGAP0eng - iTunNORM 0000005F 00000000 00000376 00000000 000084DB 00000000 000065E5 00000000 0000A47D 00000000eng - iTunSMPB 00000000 00000210 00000B48 0000000000291DA8 00000000 000EE29D 00000000 00000000 00000000 00000000 00000000 00000000Aortic, Sys & Dias Mur, Sitting, BellAorticUniversity of Michigan Heart Sound and Murmur Library, track 17/23200761125.34eng - Produced by The Learning Resource Center - Office of Medical Education copyright 2007 The Regents Of The University Of Michigan. All rights reserved.eng - iTunPGAP0eng - iTunNORM 00000082 00000000 000003E6 00000000 00006CAC 00000000 00006D90 00000000 000058E0 00000000eng - iTunSMPB 00000000 00000210 0000078A 0000000000291866 00000000 000EDF59 00000000 00000000 00000000 00000000 00000000 00000000Aortic, Early Dias Mur, Sitting, BellAorticUniversity of Michigan Heart Sound and Murmur Library, track 16/23200761908.973eng - Produced by The Learning Resource Center - Office of Medical Education copyright 2007 The Regents Of The University Of Michigan. All rights reserved.eng - iTunPGAP0eng - iTunNORM 00000105 00000000 000003F6 00000000 00005D0F 00000000 00006D93 00000000 00003AAC 00000000eng - iTunSMPB 00000000 00000210 000009E9 0000000000299D07 00000000 000F1054 00000000 00000000 00000000 00000000 00000000 00000000Apex, Holo Sys Mur, Supine, BellApexUniversity of Michigan Heart Sound and Murmur Library, track 9/23200760237.223eng - Produced by The Learning Resource Center - Office of Medical Education copyright 2007 The Regents Of The University Of Michigan. All rights reserved.eng - iTunPGAP0eng - iTunNORM 00000030 00000000 000000F1 00000000 0000B4D0 00000000 00003224 00000000 00000FB6 00000000eng - iTunSMPB 00000000 00000210 00000874 0000000000287E7C 00000000 000EA7D7 00000000 00000000 00000000 00000000 00000000 00000000