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EVERYTHING YOU NEED TO KNOW ABOUT MURMURS Emma McEwen and Harish Bava Reviewed by Dr Kajal Aubeeluck Reminder to tutors: please change the description, summary and learning objectives on MedAll Keep this slide on here until you’ve done it (as a reminder) Here’s what we do: ■ Weekly tutorials open to all! ■ Focussed on core presentations and teaching diagnostic technique If you’re new here… ■ Bstudentsl students, for medical ■ Reviewed by doctors to ensure W elcome to accuracy T eaching ■ We’ll keep you updated about our Things! upcoming events via email and groupchats!What will we be covering today? ■ What different murmurs are there? ■ Why do they present with their associated symptoms? ■ How do you investigate murmurs? ■ How do you treat and manage these patients?What are Murmurs? ■ Murmurs = audible blood flow – Valvular murmurs caused by stenosis or regurgitationWhat are Murmurs? ■ Murmurs = audible blood flow – Stenosis or regurgitationWhat are Murmurs? ■ Murmurs = audible blood flow ■ Valves closed during systole:What are Murmurs? ■ Murmurs = audible blood flow – Stenosis or regurgitation ■ Valves closed during systole: – Mitral valve – Tricuspid valveWhat are Murmurs? ■ Murmurs = audible blood flow – Stenosis or regurgitation ■ Valves closed during systole: – Mitral valve – Tricuspid valve ■ Valves closed during diastole:What are Murmurs? ■ Murmurs = audible blood flow – Stenosis or regurgitation ■ Valves closed during systole: – Mitral valve – Tricuspid valve ■ Valves closed during diastole: – Aortic valve – Pulmonary valveWhat are Murmurs? ■ Murmurs = audible blood flow – Stenosis or regurgitation ■ Valves closed during systole: – Mitral valve – Tricuspid valve ■ Valves closed during diastole: – Aortic valve – Pulmonary valve ■ Systolic murmurs: – Stenosis of valves open during systole (aortic / pulmonary)What are Murmurs? ■ Murmurs = audible blood flow – Stenosis or regurgitation ■ Valves closed during systole: – Mitral valve – Tricuspid valve ■ Valves closed during diastole: – Aortic valve – Pulmonary valve ■ Systolic murmurs: – Stenosis of valves open during systole (aortic / pulmonary) – Regurgitation of valves closed during systole (mitral / tricuspid)What are Murmurs? ■ Murmurs = audible blood flow – Stenosis or regurgitation ■ Valves closed during systole: – Mitral valve – Tricuspid valve ■ Valves closed during diastole: – Aortic valve – Pulmonary valve ■ Diastolic murmurs: – Stenosis of valves open during diastole (mitral/tricuspid)What are Murmurs? ■ Murmurs = audible blood flow – Stenosis or regurgitation ■ Valves closed during systole: – Mitral valve – Tricuspid valve ■ Valves closed during diastole: – Aortic valve – Pulmonary valve ■ Diastolic murmurs: – Stenosis of valves open during diastole (mitral/tricuspid) – Regurgitation of valves closed during diastole (aortic/pulmonary)Examining Murmurs ■ Assessment for murmurs is performed when listening to Heart Sounds ■ Where do you listen for heart sounds?Examining Murmurs ■ Assessment for murmurs is performed when listening to Heart Sounds ■ Where do you listen? – AORTIC - 2nd intercostal space RIGHT sternal border – PULMONARY - 2nd intercostal space LEFT sternal border – TRICUSPID - 4th intercostal space LEFT sternal border – midclavicular linecostal space ■ You may also feel a palpable thrill which is a palpable vibration caused by a murmurExamining Murmurs A Place To Meet ■ Assessment for murmurs is performed when listening to Heart Sounds ■ Where do you listen? – AORTIC - 2nd intercostal space RIGHT sternal border – PULMONARY - 2nd intercostal space LEFT sternal border – TRICUSPID - 4th intercostal space LEFT sternal border – midclavicular linecostal space ■ You may also feel a palpable thrill which is a palpable vibration caused by a murmurExamining Murmurs ■ What are the normal heart sounds? – S1 = closure of AV valves (end of diastole, start of systole) – S2 = closure of aortic and pulmonary valves (end of systole, start of diastole) – S3 and S4 = extra noises during diastole caused by rapid filling and turbulent blood flow ■ Not always pathological ■ When examining, to identify the difference between S1 and S2, palpate the carotid artery – ALWAYS LISTEN FIRST ■ To identify bruits incase of carotid stenosis – Can accidentally dislodge and risk a stroke ■ How do you exacerbate murmurs?Examining Murmurs Manoeuvers to exacerbate Murmurs: ■ RILE – Right sided murmurs (pulmonary, tricuspid) - exacerbated by Inspiration – Left sided murmurs (aortic, mitral) - exacerbated by Expiration ■ During inspiration, there is increased venous return to right side of the heart via the vena cava and reduced blood flow in the pulmonary vessels ■ During expiration, there is increased venous return to the left side of the heart via the pulmonary vein and reduced blood flow via the vena cavaExamining Murmurs Manoeuvers to exacerbate Murmurs: ■ Ask the patient to turn to their left side - exacerbates mitral stenosis – Brings mitral valve closest to chest wall ■ Listening to axilla - mitral regurgitation radiates to axilla – Direction of turbulent blood flow is towards axilla ■ Listening to carotids - aortic stenosis radiates to carotids – Direction of turbulent blood flow is towards the carotids ■ Sitting patient forward - exacerbates aortic regurgitation – Brings aortic valve closest to chest wallGrading MurmursSYSTOLIC MURMURS Emma McEwenAortic Stenosis: Aetiology ■ Calcific degenerative disease – Bicuspid aortic valve (unicuspid / quadricuspid valves)Aortic Stenosis: Aetiology ■ Calcific degenerative disease – Age-related – Bicuspid aortic valve (unicuspid / quadricuspid valves) ■ Rheumatic fever (more common in less developed countries) – Often mixed aortic stenosis & regurgitationAortic Stenosis: Aetiology ■ Calcific degenerative disease – Age-related – Bicuspid aortic valve (unicuspid / quadricuspid valves) ■ Rheumatic fever (more common in less developed countries) – Often mixed aortic stenosis & regurgitation ■ Radiation therapyAortic Stenosis: Aetiology ■ Calcific degenerative disease – Age-related – Bicuspid aortic valve (unicuspid / quadricuspid valves) ■ Rheumatic fever (more common in less developed countries) – Often mixed aortic stenosis & regurgitation ■ Radiation therapy ■ Infective endocarditisAortic Stenosis: Pathophysiology ■ Aortic orifice narrows – Fibrosis → leaflet thickeningon → stiff & immobile valve leafletsAortic Stenosis: Pathophysiology ■ Aortic orifice narrows – Atherosclerosis & calcification → stiff & immobile valve leaflets – Fibrosis → leaflet thickening ■ LV outflow tract obstruction – Increased pressure gradient → concentric hypertrophy (thickening) – Diastolic dysfunction → heart failureAortic Stenosis: Pathophysiology ■ Aortic orifice narrows – Atherosclerosis & calcification → stiff & immobile valve leaflets – Fibrosis → leaflet thickening ■ LV outflow tract obstruction – Increased pressure gradient → concentric hypertrophy (thickening) – Diastolic dysfunction → heart failure ■ Ischaemia & heart failure → decreased coronary perfusion – Hypertrophied ventricle requires more oxygenAortic Stenosis: Presentation ■ Triad: – Dyspnoea ■ Often first symptom ■ Reduced exercise tolerance ■ Due to diastolic dysfunction: inability to sufficiently increase cardiac output NYHA Class Symptoms I No limitation of physical activity II Slight limitation of physical activity III Marked limitation of physical activity IV Symptoms at restAortic Stenosis: Presentation ■ Triad: – Dyspnoea ■ Often first symptom ■ Reduced exercise tolerance ■ Due to diastolic dysfunction: inability to sufficiently increase cardiac output – Angina ■ Due to increased oxygen demand of LV ■ Often concurrent coronary artery diseaseAortic Stenosis: Presentation ■ Triad: – Dyspnoea ■ Often first symptom ■ Reduced exercise tolerance ■ Due to diastolic dysfunction: inability to sufficiently increase cardiac output – Angina ■ Due to increased oxygen demand of LV ■ Often concurrent coronary artery disease – Syncope ■ Hypotension due to: – Exercise-induced vasodilation – Inability to sufficiently increase cardiac output ■ Often concurrent arrhythmiasAortic Stenosis: Presentation ■ Triad: – Dyspnoea – Angina – Syncope ■ Heart failure symptoms – Paroxysmal nocturnal dyspnoea – Orthopnoea – Dyspnoea on exertion – Bilateral lower limb or pulmonary oedemaAortic Stenosis: Presentation ■ Triad: – Dyspnoea – Angina – Syncope ■ Heart failure symptoms ■ Examination: – Harsh ejection systolic murmur ■ Murmur radiates to carotids ■ Gallavardin phenomenon: murmur with musical quality at apex ■ Dynamic manoeuvres: loudest sitting forward & during expirationAortic Stenosis: Presentation ■ Triad: – Dyspnoea – Angina – Syncope ■ Heart failure symptoms ■ Examination: – Harsh ejection systolic murmur ■ Murmur radiates to carotids ■ Gallavardin phenomenon: murmur with musical quality at apex ■ Dynamic manoeuvres: loudest sitting forward & during expirationAortic Stenosis: Presentation ■ Triad: – Dyspnoea – Angina – Syncope ■ Heart failure symptoms ■ Examination: – Harsh ejection systolic murmur ■ Murmur radiates to carotids ■ Gallavardin phenomenon: murmur with musical quality at apex ■ Dynamic manoeuvres: loudest sitting forward & during expirationAortic Stenosis: Presentation ■ Triad: – Dyspnoea – Angina – Syncope ■ Heart failure symptoms ■ Examination: – Harsh ejection systolic murmur – Pulsus parvus et tardus ■ Slow-rising & low volume carotid pulse ■ (May not be present in elderly due to stiff vessels)Aortic Stenosis: Presentation ■ Triad: – Dyspnoea – Angina – Syncope ■ Heart failure symptoms ■ Examination: – Harsh ejection systolic murmur – Pulsus parvus et tardus – Second heart sound (S2): ■ Soft / absent ■ Reverse splitting (pulmonary valve closes before aortic valve)Aortic Stenosis: Presentation ■ Triad: – Dyspnoea – Angina – Syncope ■ Heart failure symptoms ■ Examination: – Harsh ejection systolic murmur – Pulsus parvus et tardus – Second heart sound (S2) – Other features: ■ Narrow pulse pressure ■ Heaving apex beat or systolic thrill ■ Signs of heart failureAortic Stenosis: Presentation ■ Triad: – Dyspnoea – Angina – Syncope ■ Heart failure symptoms ■ Examination: – Harsh ejection systolic murmur – Pulsus parvus et tardus – Second heart sound (S2) – Other features: ■ Narrow pulse pressure ■ Heaving apex beat or systolic thrill ■ Signs of heart failure What initial investigations can we consider?Aortic Stenosis: Investigations ■ Initial investigations – ECG ■ LV strain → LVH ■ Concurrent arrhythmiasAortic Stenosis: Investigations ■ Initial investigations – ECG ■ LV strain → LVH ■ Concurrent arrhythmias – CXRAortic Stenosis: Investigations ■ Initial investigations – ECG ■ LV strain → LVH ■ Concurrent arrhythmias – CXR – Transthoracic echo (TTE) ■ Transvalvular velocity ■ Mean & peak pressure gradient ■ Aortic valve area ■ LVEF & wall thicknessAortic Stenosis: Investigations ■ Initial investigations – ECG – CXR – Transthoracic echo (TTE) ■ Prognostic investigations – Exercise stress testing ■ Unmasks symptoms in asymptomatic patientsAortic Stenosis: Investigations ■ Initial investigations – ECG – CXR – Transthoracic echo (TTE) ■ Prognostic investigations – Exercise stress testing ■ Unmasks symptoms in asymptomatic patients – Dobutamine stress echo ■ Low-gradient aortic stenosisAortic Stenosis: Investigations ■ Initial investigations – ECG – CXR – Transthoracic echo (TTE) ■ Prognostic investigations – Exercise stress testing ■ Unmasks symptoms in asymptomatic patients – Dobutamine stress echo ■ Low-gradient aortic stenosis – BNP / NT-proBNP ■ Assesses heart failure ■ Predicts timing of intervention for asymptomatic patientsAortic Stenosis: Investigations ■ Initial investigations – ECG – CXR – Transthoracic echo (TTE) ■ Prognostic investigations – Exercise stress testing ■ Unmasks symptoms in asymptomatic patients – Dobutamine stress echo ■ Low-gradient aortic stenosis – BNP / NT-proBNP ■ Assesses heart failure ■ Predicts timing of intervention for asymptomatic patients – cMRI ■ Quantifies myocardial fibrosisAortic Stenosis: Investigations ■ Initial investigations – ECG – CXR – Transthoracic echo (TTE) ■ Prognostic investigations – Exercise stress testing – Dobutamine stress echo – BNP / NT-proBNP – cMRI ■ Investigations prior to intervention – Coronary angiography – Transoesophageal echo (TOE) – Multi-slice CT (MSCT)SBA A 59-year-old man presents to the outpatient clinic with symptoms of angina, exertional dyspnoea, and fatigue. Additionally, he has experienced several mellitus and hypertension. past month. He has a background of type 2 diabetes On examination, a grade 3 ejection systolic murmur is noted with radiation tothe carotids. What is the most appropriate definitive management for this patient based on the likely diagnosis? A. Balloon valvuloplasty B. Echocardiogram surveillance C. Surgical aortic valve replacement with mechanical valve D. Surgical aortic valve replacement with bioprosthetic valve E. Transcatheter aortic valve replacement (TAVI)SBA A 59-year-old man presents to the outpatient clinic with symptoms of angina, exertional dyspnoea, and fatigue. Additionally, he has experienced several mellitus and hypertension. past month. He has a background of type 2 diabetes On examination, a grade 3 ejection systolic murmur is noted with radiation tothe carotids. What is the most appropriate definitive management for this patient based on the likely diagnosis? A. Balloon valvuloplasty B. Echocardiogram surveillance C. Surgical aortic valve replacement with mechanical valve D. Surgical aortic valve replacement with bioprosthetic valve E. Transcatheter aortic valve replacement (TAVI)Aortic Stenosis: Management ■ Definitive management: – Surgical aortic valve replacement (AVR) – Transcatheter aortic valve implantation (TAVI) ■ Note: mechanical valves require lifelong anti-coagulation with warfarin (INR 3.5)Aortic Stenosis: Management ■ Definitive management: – Surgical aortic valve replacement (AVR) – Transcatheter aortic valve implantation (TAVI) ■ Indications for definitive management – Symptomatic ■ High mortality rate if untreated: average survival 2-3 years ■ High risk of sudden cardiac death ■ Not recommended if severe comorbiditiesAortic Stenosis: Management ■ Definitive management: – Surgical aortic valve replacement (AVR) – Transcatheter aortic valve implantation (TAVI) ■ Indications for definitive management – Symptomatic ■ High mortality rate if untreated: average survival 2-3 years ■ High risk of sudden cardiac death ■ Not recommended if severe comorbidities – Severe aortic stenosis (as measured on TOE)Aortic Stenosis: Management ■ Definitive management: – Surgical aortic valve replacement (AVR) – Transcatheter aortic valve implantation (TAVI) ■ Indications for definitive management – Symptomatic ■ High mortality rate if untreated: average survival 2-3 years ■ High risk of sudden cardiac death ■ Not recommended if severe comorbidities – Severe aortic stenosis (as measured on TOE) – Other indications: ■ LVEF <50% ■ Undergoing other cardiac surgeryAortic Stenosis: Management ■ Definitive management: – Surgical aortic valve replacement (AVR) – Transcatheter aortic valve implantation (TAVI) ■ Palliative management(if not suitable for cardiac surgery): – Percutaneous balloon valvotomyAortic Stenosis: Management ■ Definitive management: – Surgical aortic valve replacement (AVR) – Transcatheter aortic valve implantation (TAVI) ■ Palliative management (if not suitable for cardiac surgery): – Percutaneous balloon valvotomy ■ Conservative managementin mild / asymptomatic aortic stenosis: – Monitoring: 6-monthly / yearly – Controlling hypertension – Maintaining sinus rhythm – Treating heart failureSBA A 59-year-old man presents to the outpatient clinic with symptoms ofangina, exertional dyspnoea, and fatigue. Additionally, he has experienced several mellitus and hypertension. past month. He has a background of type 2 diabetes On examination, a grade 3 ejection systolic murmur is noted with radiation to the carotids. What is the most appropriate definitive management for this patient based on the likely diagnosis? A. Balloon valvuloplasty B. Echocardiogram surveillance C. Surgical aortic valve replacement with mechanical valve D. Surgical aortic valve replacement with bioprosthetic valve E. Transcatheter aortic valve replacement (TAVI)SBA A 59-year-old man presents to the outpatient clinic with symptoms of angina, exertional dyspnoea, and fatigue. Additionally, he has experienced several mellitus and hypertension. past month. He has a background of type 2 diabetes On examination, a grade 3 ejection systolic murmur is noted with radiation tothe carotids. What is the most appropriatedefinitive managementfor this patient based on the likely diagnosis? A. Balloon valvuloplasty B. Echocardiogram surveillance C. Surgical aortic valve replacement with mechanical valve D. Surgical aortic valve replacement with bioprosthetic valve E. Transcatheter aortic valve replacement (TAVI)SBA A 59-year-old man presents to the outpatient clinic with symptoms of angina, exertional dyspnoea, and fatigue. Additionally, he has experienced several mellitus and hypertension. past month. He has a background oftype 2 diabetes On examination, a grade 3 ejection systolic murmur is noted with radiation tothe carotids. What is the most appropriatedefinitive managementfor this patient based on the likely diagnosis? A. Balloon valvuloplasty B. Echocardiogram surveillance C. Surgical aortic valve replacement with mechanical valve D. Surgical aortic valve replacement with bioprosthetic valve E. Transcatheter aortic valve replacement (TAVI)SBA A 59-year-old man presents to the outpatient clinic with symptoms of angina, exertional dyspnoea, and fatigue. Additionally, he has experienced several episodes of syncope in the past month. He has a background of type 2 diabetes mellitus and hypertension. On examination, a grade 3 ejection systolic murmur is noted with radiation tothe carotids. What is the most appropriate definitive management for this patient based on the likely diagnosis? A. Balloon valvuloplasty - patient is well enough to undergo definitive treatment B. Echocardiogram surveillance - patient is symptomatic → treatment required C. Surgical aortic valve replacement with mechanical valve- patient is young with no contraindications to surgical valve replacement D. Surgical aortic valve replacement with bioprosthetic valve- patient is E. Transcatheter aortic valve replacement (TAVI)- patient is too youngMitral Regurgitation: Aetiology ■ Infective endocarditis – Mitral valve most likely to be affected if previously normal valve – Vegetations prevent valve closure – Abnormal valves more likely to be affected by IEMitral Regurgitation: Aetiology ■ Infective endocarditis – Mitral valve most likely to be affected if previously normal valve – Vegetations prevent valve closure – Abnormal valves more likely to be affected by IE What is infective endocarditis?Infective Endocarditis ■ Infection of the endocardial surface of the heart – Typically includes valvesInfective Endocarditis ■ Infection of the endocardial surface of the heart ■ Risk factors – >60 years / male – IVDU: most likely to cause tricuspid regurgitation – IV lines / haemodialysis / dental & surgical procedures – Structural heart disease / prosthesisInfective Endocarditis ■ Infection of the endocardial surface of the heart ■ Risk factors – >60 years / male – IVDU: most likely to cause tricuspid regurgitation – IV lines / haemodialysis / dental & surgical procedures – Structural heart disease / prosthesis ■ Causative organisms – Staphylococcus aureus: associated with iatrogenic IE & IVDUs – Viridans group streptococcus: community-acquired IE – Streptococci bovis: associated with ulcerative colon cancer – HACEK organismsInfective Endocarditis ■ Presentation – Acute / subacute / chronicInfective Endocarditis ■ Presentation – Acute / subacute / chronic – Non-specific presentation ■ Fever ■ Weight loss ■ Malaise ■ Night sweats ■ Myalgia / arthralgiaInfective Endocarditis ■ Presentation – Acute / subacute / chronic – Non-specific presentation ■ Fever ■ Weight loss ■ Malaise ■ Night sweats ■ Myalgia / arthralgia What specific signs might be found on examination?Infective Endocarditis ■ Presentation – Acute / subacute / chronic – Non-specific presentation – Uncommon but specific signs ■ Splinter haemorrhages ■ Janeway lesions ■ Osler’s nodes ■ Roth spotsInfective Endocarditis ■ Presentation – Acute / subacute / chronic – Non-specific presentation – Uncommon but specific signs – Right ventricular failure: tricuspid regurgitation ■ Peripheral oedema ■ Pulsatile hepatomegaly ■ Raised JVPInfective Endocarditis ■ Presentation – Acute / subacute / chronic – Non-specific presentation – Uncommon but specific signs – Right ventricular failure: tricuspid regurgitation – Left ventricular failure: mitral regurgitation ■ Pulmonary oedema ■ Dyspnoea ■ Cough with pink / frothy sputumInfective Endocarditis ■ Presentation – Acute / subacute / chronic – Non-specific presentation – Uncommon but specific signs – Right ventricular failure: tricuspid regurgitation – Left ventricular failure: mitral regurgitation – Complications ■ Pulmonary septic emboli: right-sided IE ■ Embolic stroke: left-sided IEInfective Endocarditis ■ Presentation – Acute / subacute / chronic – Non-specific presentation – Uncommon but specific signs – Right ventricular failure: tricuspid regurgitation – Left ventricular failure: mitral regurgitation – Complications ■ Investigations – Blood cultures: diagnostic – Echo: TTE → TOEInfective Endocarditis ■ Presentation – Acute / subacute / chronic – Non-specific presentation – Uncommon but specific signs – Right ventricular failure: tricuspid regurgitation – Left ventricular failure: mitral regurgitation – Complications ■ Investigations – Blood cultures: diagnostic – Echo: TTE → TOE ■ Management – Antibiotics: depends on likely causative organism – Remove source of infection (devices / catheters / lines) – Early valve surgery if heart failure / valve dysfunctionMitral Regurgitation: Aetiology ■ Infective endocarditis – Mitral valve most likely to be affected if previously normal valve – Vegetations prevent valve closure – Abnormal valves more likely to be affected by IE ■ Coronary artery disease / myocardial infarction – Papillary muscles affected by cardiac insultMitral Regurgitation: Aetiology ■ Infective endocarditis – Mitral valve most likely to be affected if previously normal valve – Vegetations prevent valve closure – Abnormal valves more likely to be affected by IE ■ Coronary artery disease / myocardial infarction – Papillary muscles affected by cardiac insult ■ Other: – Mitral valve prolapse ■ Most have trivial degree of mitral regurgitation – Rheumatic fever – CongenitalMitral Regurgitation: Presentation ■ Most patients asymptomatic – Common in otherwise healthy individuals: may not need treatmentMitral Regurgitation: Presentation ■ Most patients asymptomatic – Common in otherwise healthy individuals: may not need treatment ■ Symptoms caused by: – LV failure ■ Body’s oxygen demands exceed heart’s supply → concentric LV hypertrophy – Arrhythmias ■ Increased blood volume in left atrium → dilation – Pulmonary hypertensionMitral Regurgitation: Presentation ■ Most patients asymptomatic – Common in otherwise healthy individuals: may not need treatment ■ Symptoms caused by: – LV failure – Arrhythmias – Pulmonary hypertension ■ Pansystolic ‘blowing’ / ‘whistling’ murmur – Best heard at apex → radiates to axilla – S1 may be quiet – Severe MR: widely split S2Mitral Regurgitation: Presentation ■ Most patients asymptomatic – Common in otherwise healthy individuals: may not need treatment ■ Symptoms caused by: – LV failure – Arrhythmias – Pulmonary hypertension ■ Pansystolic ‘blowing’ / ‘whistling’ murmur – Best heard at apex → radiates to axilla – S1 may be quiet – Severe MR: widely split S2Mitral Regurgitation: Investigations ■ ECG – Broad P wave: due to atrial enlargement ■ CXR – Cardiomegaly ■ Echo – TTE: initial investigation – TOE: gold standard investigationMitral Regurgitation: Management ■ Acute – Nitrates – Diuretics – Positive inotropes – Intra-arterial balloon pump (IABP): increases cardiac outputMitral Regurgitation: Management ■ Acute – Nitrates – Diuretics – Positive inotropes – Intra-arterial balloon pump (IABP): increases cardiac output ■ Heart failure – ACE inhibitors – Beta-blockers – SpironolactoneMitral Regurgitation: Management ■ Acute – Nitrates – Diuretics – Positive inotropes – Intra-arterial balloon pump (IABP): increases cardiac output ■ Heart failure – ACE inhibitors – Beta-blockers – Spironolactone ■ Surgery: definitive treatment – Indications: acute or severe disease – Mitral valve repair >> replacement if possibleSystolic Murmurs in CHD ■ Tetralogy of Fallot – 4 features: ■ Systolic murmurs: – Stenosis of valves open during systole (aortic / pulmonary) – Regurgitation of valves closed during systole (mitral / tricuspid)Systolic Murmurs in CHD ■ Tetralogy of Fallot – 4 features: ■ Ventricular septal defect (no murmur) ■ Right ventricular hypertrophy (no murmur) ■ Overriding aorta (no murmur) ■ Right ventricular outflow tract obstruction & pulmonary stenosis ■ Systolic murmurs: – Stenosis of valves open during systole (aortic / pulmonary) – Regurgitation of valves closed during systole (mitral / tricuspid)Systolic Murmurs in CHD ■ Tetralogy of Fallot – 4 features: ■ Ventricular septal defect (no murmur) ■ Right ventricular hypertrophy (no murmur) ■ Overriding aorta (no murmur) ■ Right ventricular outflow tract obstruction & pulmonary stenosis – Associated with ejection systolic murmur – Cyanotic CHD: presents with ‘Tet’ spells ■ Systolic murmurs: – Stenosis of valves open during systole (aortic / pulmonary) – Regurgitation of valves closed during systole (mitral / tricuspid)Systolic Murmurs in CHD ■ Tetralogy of Fallot – Associated with ejection systolic murmur ■ Coarctation of the Aorta – Narrowing of aorta ■ Similar to aortic stenosis with ‘delay’ → mid-systolic murmur – Presents with reduced femoral pulses & ‘rib notching’ on CXR ■ Systolic murmurs: – Stenosis of valves open during systole (aortic / pulmonary) – Regurgitation of valves closed during systole (mitral / tricuspid)Systolic Murmurs in CHD ■ Tetralogy of Fallot – Associated with ejection systolic murmur ■ Coarctation of the Aorta – Associated with mid-systolic murmur ■ Atrial Septal Defect (ASD) – Increased blood flow through pulmonary valve ■ Similar to pulmonary stenosis → ejection systolic murmur ■ Systolic murmurs: – Stenosis of valves open during systole (aortic / pulmonary) – Regurgitation of valves closed during systole (mitral / tricuspid)Systolic Murmurs in CHD ■ Tetralogy of Fallot – Associated with ejection systolic murmur ■ Coarctation of the Aorta – Associated with mid-systolic murmur ■ Atrial Septal Defect (ASD) – Associated with ejection systolic murmur ■ Ventricular Septal Defect (VSD) – Blood flow LV→RV throughout systole ■ Associated with pan-systolic murmur – Louder murmur = smaller defect ■ Due to increased resistance through smaller defects ■ Systolic murmurs: – Stenosis of valves open during systole (aortic / pulmonary) – Regurgitation of valves closed during systole (mitral / tricuspid)Systolic Murmurs in CHD ■ Tetralogy of Fallot – Associated with ejection systolic murmur ■ Coarctation of the Aorta – Associated with mid-systolic murmur ■ Atrial Septal Defect (ASD) – Associated with ejection systolic murmur ■ Ventricular Septal Defect (VSD) – Associated with pan-systolic murmur ■ Systolic murmurs: – Stenosis of valves open during systole (aortic / pulmonary) – Regurgitation of valves closed during systole (mitral / tricuspid)SBA A 3-week-old child is brought into the emergency department. His mother reports that he was initially well, but over the last few days, she has noticed that and sweaty when feeding. He was born at term with no complications. Oness, pale examination, his growth chart shows poor growth and he is tachypnoeic and using his accessory muscles to breathe. On auscultation, he has a pansystolic murmur at his lower left sternal edge and a loud P2. Which of the following is the likely cause of this presentation? A. Tetralogy of Fallot B. Coarctation of the aorta C. Mitral regurgitation D. Ventricular septal defect E. Atrial septal defectSBA A 3-week-old child is brought into the emergency department. His mother reports that he was initially well, but over the last few days, she has noticed that and sweaty when feeding. He was born at term with no complications. Oness, pale examination, his growth chart shows poor growth and he is tachypnoeic and using his accessory muscles to breathe. On auscultation, he has a pansystolic murmur at his lower left sternal edge and a loud P2. Which of the following is the likely cause of this presentation? A. Tetralogy of Fallot B. Coarctation of the aorta C. Mitral regurgitation D. Ventricular septal defect E. Atrial septal defectSBA A 3-week-old child is brought into the emergency department. His mother reports that he was initially well, but over the last few days, she has noticed that and sweaty when feeding. He was born at term with no complications. Oness, pale examination, his growth chart shows poor growth and he is tachypnoeic and using his accessory muscles to breathe. On auscultation, he has a pansystolic murmur at his lower left sternal edge and a loud P2. Which of the following is the likely cause of this presentation? A. Tetralogy of Fallot - ejection systolic murmur & ‘Tet’ spells B. Coarctation of the aorta - mid-systolic murmur & reduced femoral pulses C. Mitral regurgitation - pansystolic murmur at apex with no loud P2 D. Ventricular septal defect - pansystolic murmur in tricuspid area with loud P2 & heart failure symptoms E. Atrial septal defect - ejection systolic murmurDiastolic Murmurs Harish BavaWhat is happening during diastole? ■ Starts with closure of aortic/pulmonary valves ■ Ventricular diastole - relax of ventricles ■ Atrial diastole - filling of atria with blood from IVC/SVC/Pulmonary vein ■What is happening during diastole? ■ Starts with closure of aortic/pulmonary valves ■ Ventricular diastole - relax of ventricles ■ Atrial diastole - filling of atria with blood from IVC/SVC/Pulmonary vein ■ Mitral/Tricuspid valves open- blood starts flowing into ventricles ■ Atrial systole - contraction of atria to push blood into ventricles and increase pressure ■ Ends with closure of mitral/tricuspid valvesWhat are the diastolic murmurs? ■ Starts with closure of aortic/pulmonary valves ■ Ventricular diastole - relax of ventricles ■ Atrial diastole - filling of atria with blood from IVC/SVC/Pulmonary vein ■ Mitral/Tricuspid valves open- blood starts flowing into ventricles ■ Atrial systole - contraction of atria to push blood into ventricles and increase pressure ■ Ends with closure of mitral/tricuspid valvesWhat are the diastolic murmurs? ■ There are two points during diastole where we see common murmurs ■ Start - closure of the aortic/pulmonary valves – Gives rise to aortic and pulmonary regurgitation ■ Opening of mitral/tricuspid valves – Gives rise to mitral/tricuspid stenosisAortic Regurgitation ■ Backflow of blood from aorta into left ventricle secondary to a leaky aortic aortic root and ascending aortaaortic valve or distortion/dilation of the ■ What are the different causes?Aortic Regurgitation: AetiologyAortic Regurgitation: Aetiology Affecting the Aortic valve Affecting the aortic root Chronic Presentation ● Rheumatic Fever ● Bicuspid Aortic Valve ● Calcific Valve Disease ● Spondylarthropathies ● Connective Tissue (Ankylosing Spondylitis) Diseases (Rheumatoid ● Hypertension arthritis, SLE) ● Syphilis ● Bicuspid Aortic Valve ● Marfan's, Ehler-Danlos syndrome Acute presentation Infective Endocarditis Aortic DissectionBicuspid Aortic Valve ■ Aortic valve usually has three leaflets ■ In some patients, two of these leaflets fuse together during fetal development ■ This is often an inherited phenomenon ■ Results in an aortic valve consisting of only two leafletsBicuspid Aortic Valve ■ Leads to narrowing (stenosis) or leaking (regurgitation) or enlargement of the aorta – Over time can lead to LVH and heart failure due to overworking of the heart – Can lead to downstream aortic aneurysms – Enlarged aortas increase risk of aortic dissection ■ Often asymptomatic, but can present with: – Chest pain, fatigue, SOB, pallor, arrhythmias ■ Must be monitored with regular dental hygiene because of an increased risk of infective endocarditisAortic Regurgitation: Pathophysiology ■ Calcific Valve Disease – Age, comorbidities increase risk – Leads to atherosclerosis and calcification of valves leading to regurgitation ■ Connective Tissue Disease – Leads to fibrosis of the valve and thickening of the base – Marfan’s - anti-fibrillin 1 causes dilation of aortic root – EDS - defect in synthesis of collagen, reduces tensile strength and increases aortic friability and fragility ■ Hypertension – rooteases stress on the valve leaflets leading to dilation of the aortic ■ Syphilis – Syphilitic aortitis - inflammation and weakening and dilation of aortic rootAortic Regurgitation: F eatures and Presentation ■ Symptoms: – SOBst pain – Peripheral oedema – Fatigue – Palpitations – Syncope – Irregular heartbeatSBA A 57 year-old patient presents to the Emergency Department with severe radiates to the back. What would you see when you take BP measurementseels that it from both arms? A - L: 100/60 R: 110/65 B - L: 200/120 R: 170/110 C - L: 110/70 R: 80/60 D - L: 190/110 R: 180/100SBA A 57 year-old patient presents to the Emergency Department with severe chest central chest pain. He describes the pain as a tearing sensation and feels that it radiates to the back. What would you see when you take BP measurements from both arms? A - L: 100/60 R: 110/65 B - L: 200/120 R: 170/110 - this is a classic presentation of aortic dissection, and it presents with a >20 mmHg variation in BP between both arms C - L: 110/70 R: 80/60 D - L: 190/110 R: 180/100SBA A 57 year-old patient presents to the Emergency Department with severe chest radiates to the back. What investigation is diagnostic of this condition?s that it A - Chest X-ray B - Transthoracic echocardiogram C - MRI of the thorax D - CT of the chest, abdomen and pelvis E - Transoesophageal echocardiogramSBA A 57 year-old patient presents to the Emergency Department with severe chest radiates to the back. What investigation is diagnostic of this condition?s that it A - Chest X-ray - this may show a widened mediastinum but it isnot diagnositc B - Abdominal ultrasound - this would be useful in monitoring of a AAA C - MRI of the thorax - would not be considered D - CT of the chest, abdomen and pelvis - this is the diagnostic investigation.A false lumen is diagnostic of aortic dissection E - Transoesophageal echocardiogram - this is second line for patients who are too unstable to undergo CTAortic Regurgitation: F eatures ■ Early diastolic murmur – This is because you can hear the blood rushing in from the aorta immediately at the start of diastole – Intensity increased by handgrip ■anAsking patient to repeatedly make a fist in the hand ■ Increases afterload to the heart, increased work of the heart, therefore increasing intensity of the murmurAortic Regurgitation: F eatures ■ Early diastolic murmur – This is because you can hear the blood rushing in from the aorta immediately at the start of diastole – Intensity increased by handgrip ■anAsking patient to repeatedly make a fist in the hand ■ Increases afterload to the heart, increased work of the heart, therefore increasing intensity of the murmurAortic Regurgitation: F eatures ■ Early diastolic murmur – This is because you can hear the blood rushing in from the aorta immediately at the start of diastole – Characteristically high-pitched and ‘blowing’ ■ Collapsing pulse (Water hammer pulse, Corrigan pulse) – Elicited by palpating both the radial and brachial pulse and rapidly raising the arm – As AR worsens, it increases the volume of regurgitated blood, thus stroke volume increases to fill an empty arterial treeAortic Regurgitation: F eatures ■ Early diastolic murmur – This is because you can hear the blood rushing in from the aorta immediately at the start of diastole – Characteristically high-pitched and ‘blowing’ ■ Collapsing pulse (Water hammer pulse, Corrigan pulse) – Elicited by palpating both the radial and brachial pulse and rapidly raising the arm ■ Wide pulse pressure – As blood is regurgitated, systolic pressure increases to maintain perfusion whilst diastolic pressure is reducedAortic Regurgitation: F eatures ■ Early diastolic murmur – This is because you can hear the blood rushing in from the aorta immediately at the start of diastole ■ Collapsing pulse (Water hammer pulse, Corrigan pulse) – Elicited by palpating both the radial and brachial pulse and rapidly raising the arm ■ Wide pulse pressure – As blood is regurgitated, systolic pressure increases to maintain perfusion whilst diastolic pressure is reduced ■ De Quincke’s sign – Nailbed pulsation due to severe AR ■ De Musset’s sign – Rhythmic bobbing of the head in synchrony with heartbeat – Caused by a strong pulse felt in the head due to severe ARAortic Regurgitation: Investigation ■ The main investigation for aortic regurgitation is echocardiography ■ At the undergraduate level, you are not expected to be able to interpret an echocardiogram!Aortic Regurgitation: Management ■ Medical management of heart failure: – Lifestyle advice to improve any modifiable risk factors ■ Smoking cessation, diet, exercise – Beta-blockers (e.g. propranolol) and ACE Inhibitors (e.g. ramipril) – Aldosterone antagonists (e.g. spironolactone) – Diuretics (e.g. furosemide) for acute exacerbations – Other specialist medications such as ivabradine, digoxin, hydralazine – Annual influenza vaccine – One off pneumococcal vaccineAortic Regurgitation: Management ■ Medical management of heart failure: – Lifestyle advice to improve any modifiable risk factors ■ Smoking cessation, diet, exercise – Beta-blockers (e.g. propranolol) and ACE Inhibitors (e.g. ramipril) – Aldosterone antagonists (e.g. spironolactone) – Diuretics (e.g. furosemide) for acute exacerbations – Other specialist medications such as ivabradine, digoxin, hydralazine – Annual influenza vaccine – One off pneumococcal vaccine ■ Surgical management – Aortic valve replacement ■ Indicated in symptomatic patients with severe AR or asymptomatic patients with severe AR who have LV systolic dysfunctionMitral Stenosis ■ Obstruction of blood flow across mitral valve from left atrium to left ventricle ■ Leads to increased pressure within left atrium, pulmonary vasculature and right side of the heart ■ Caused by RHEUMATIC FEVER – This is the most common cause and there are very few other causes, all of which are very rareRheumatic F ever ■ Develops following an immunological reaction 2-4 weeks after a Streptococcus Pyogenes infection – Activates innate immune system leading to antigen presentation to T cells – B and T cells produce both IgG and IgM antibodies and CD4+ T cells are activated – There is a cross-reactive immune response mediated by molecular mimicry – Strep Pyogenes cell wall contains a M protein which is a virulence factor that is highly antigenic ■ muscle of arteries this M protein cross-react with myosin and the smooth – This response leads to clinical features of rheumatic feverRheumatic F ever ■ Clinical Features: – Raised or rising streptococci antibodies – Positive throat swab or rapid group A streptococcal antigen test – Erythema marginatum – Polyarthritis – Valvulitis - mitral stenosis – Raised ESR or CRP – Pyrexia – Arthralgia – Prolonged PR interval ■ Management – Oral penicillin V – NSAIDs – Treatment of complicationsMitral Stenosis: Presentation and F eatures Patients present with: ■ Dyspnoea – Increased left atrial pressure results in pulmonary venous hypertension ■ Haemoptysis – Due to pulmonary pressures and vascular congestion – Ranges from pink frothy sputum to sudden haemorrhage ■ Haemorrhage secondary to rupture of thin-walled and dilated bronchial veins ■ Atrial Fibrillation – Increased left atrial pressures leads to left atrial enlargement ■ Malar flush – Mitral stenosis causes CO2 retention and vasodilation of arterioles in cheeksMitral Stenosis: Presentation and F eatures Other Features: ■ Mid-late diastolic murmur – Best heard in expiration – Characteristically ‘rumbling’ ■ Loud S1 ■ Opening snap – Mitral valve leaflets are still mobile ■ Low volume pulse Features of severe MS ■ Length of murmur increases ■ Opening snap becomes closer to S2Mitral Stenosis: Presentation and F eatures Other Features: ■ Mid-late diastolic murmur – Best heard in expiration – Characteristically ‘rumbling’ ■ Loud S1 ■ Opening snap – Mitral valve leaflets are still mobile ■ Low volume pulse Features of severe MS ■ Length of murmur increases ■ Opening snap becomes closer to S2Mitral Stenosis: Investigations ■ CXR – Left atrial enlargement ■ The white dotted line is the enlarged left atrium ■ Echocardiography – Can see a ‘tight’ mitral valve with a smaller cross-sectional areaMitral Stenosis: Management ■ Treat the atrial fibrillation – Warfarin is recommended as anticoagulation for patients with moderate/severe MS – DOACs may be suitable for mild MS ■ Asymptomatic patients – Monitor with regular echocardiograms ■ Symptomatic patients – Percutaneous mitral balloon valvotomy – Mitral valve surgery ■ Commissurotomy – Opening up fused valvular flaps of the mitral valve ■ Valve replacement – Requires lifelong warfarin with a target INR of 3.5Other Murmurs ■ Graham-Steel murmur – Pulmonary regurgitation, early diastolic, high-pitched and ‘blowing’ in character ■Other Murmurs ■ Graham-Steel murmur – Pulmonary regurgitation, early diastolic, high-pitched and ‘blowing’ in character ■ Austin-Flint murmur – Mid-late diastolic, severe aortic regurgitation, ‘rumbling’ in character ■Other Murmurs ■ Graham-Steel murmur – Pulmonary regurgitation, early diastolic, high-pitched and ‘blowing’ in character ■ Austin-Flint murmur – Mid-late diastolic, severe aortic regurgitation, ‘rumbling’ in character ■ Continuous machine-like murmur – Patent ductus arteriosus ■ Typically seen in newborn babies ■ Treated with indomethacin and ibuprofen to help close it ■ Sometimes kept open using Prostaglandin E1 in cyanotic CHD to surgery oxygenation to the body beforeOther Murmurs ■ Graham-Steel murmur – Pulmonary regurgitation, early diastolic, high-pitched and ‘blowing’ in character ■ Austin-Flint murmur – Mid-late diastolic, severe aortic regurgitation, ‘rumbling’ in character ■ Continuous machine-like murmur – Patent ductus arteriosus ■ Typically seen in newborn babies ■ Treated with indomethacin and ibuprofen to help close it ■ Sometimes kept open using Prostaglandin E1 in cyanotic CHD to improve oxygenation to the body before surgery ■ Innocent Murmurs heard in children – Venous hums - turbulent blood flow in great veins - continuous blowing noise heard just below clavicles – Still’s murmur - low-pitched sound heart at lower left sternal edge – These have no radiation, no diastolic component, no added sounds or thrills, and no symptoms in the childReference: https://depts.washington.edu/physdx/heart/demo.htmlRemember ... Practice listening to as many hearts as possible, especially normal ones! The best way to get confident in murmurs is to get comfortable hearing normal heart sounds, so abnormal heart sounds are very obvious! THANKS FOR W ATCHING! TTutor 2: Harish Bava Please fill out the feedback form on Medall and see you next week!