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72 Cards in this Set

  • Front
  • Back
Closing of mitral and tricuspid (AV) valves
S1
Heard best at apex, 5th intercostal space
S1
Beginning of systole
S1
Closing of aortic and pulmonic (semilunar) valves
S2
Heard best at base (top of heart)
S2
End of systole
S2
Sound of rapid filling of the ventricles
S3
"Sloshing in"
Can be normal
Normally silent (at apex and at beginning of expiration, best L side lying with bell).
S3
Vibration of left ventricle and contraction of atria
S4
"A Stiff Wall"
ABNORMAL
Heard best at apex with bell - right before S1
S4
Heart sound that indicates possible CAD, Hx of MI, or HTN
S4
Systole
Mitral and tricuspid valves close
Pulmonary and aortic valves open

Beats with the pulse
Diastole
Aortic and pulmonary valves close
Mitral and tricuspid valves open

Beats before pulse
Systolic murmurs
Aortic stenosis
Pulmonary stenosis
Mitral and Tricuspid regurgitation
Diastolic murmurs
Mitral and tricuspid stenosis
Aortic and pulmonary regurgitation
Sound of stenosis in systole (A&P)
Crescendo to decrescendo
Sound of regurgitation in systole (M&T)
Plateau (swoosh)
Sound of stenosis in diastole (M&T)
Rumble
Plateau + crescendo
Regurgitation in diastole (A&P)
Decrescendo
These two types of murmurs are typically congenital
Pulmonary and Tricuspid
These two types of murmurs are typically acquired after birth
Aortic and Mitral
Click
Sound of aortic and pulmonary valves opening
Heard at the beginning of systole
High pitched
Does not change with inspiration
ABNORMAL
Opening snap
Sound of mitral and tricuspid valves opening
Heard at the beginning of diastole
Low pitched
Does not change with inspiration
ABNORMAL
During auscultation, one should use this side of the stethoscope to hear high pitched sounds and murmurs
Diaphragm
During auscultation, one should use this side of the stethoscope for low pitched sounds and murmurs
Bell
This grade of murmur can only be heard by a cardiologist
Grade 1
This grade of murmur is audible after listening for a little while
Grade 2
This grade of murmur is audible right away
Grade 3
This grade of murmur is associated with a thrill or palpable heart sound
Grade 4
This grade of murmur is audible with the stethoscope partially off the chest
Grade 5
This grade of murmur is audible at the bed side
Grade 6
Innocent murmur
Characterized by grade I-II-III @ LSB
Does not increase with valsalva
Common in asymptomatic adults and children
Everything ellse is normal (normal precordium, apex, S1, normal intensity and splitting of second sound, no other abnormal sounds or murmurs, no evidence of LVH)
Characteristics of non-innocent murmur
Diastolic murmur
Loud murmur (Grade IV or above)
Regurgitant murmur
Murmurs associated with a click
Abnormal 2nd heart sound - fixed split, paradoxical split or single
Regurgitation/Insufficiency
Leaking (back flow) of blood across a closed valve
Stenosis
Obstruction of forward flow across an opened valve
Atrioventricular valves
Bicuspid (Mitral) and Tricuspid
Semilunar valves
Aortic and Pulmonary (Both Tricuspids)
Spectrum of Valvular heart disease (Left-sided)
Aortic valve can be regurg or stenosis (With regurg being acute or chronic and stenosis being chronic)

Mitral valve can be regurg or stenosis (with regurg being acute or chronic and stenosis being chronic)
Spectrum of valvular heart disease (right-sided)
Tricuspid valve
- Endocarditis secondary to IV Drug Use
- Carcinoid HD
- Tricuspid regurg. (common, benign, may be secondary to pulm. HTN)

Pulmonic valve
- Pediatrics (pulmonary stenosis...congenital)
- Rheumatic HD

Right-sided valvular lesions change in intensity with inspiration
Aortic stenosis etiologies
Congenital...0-30 years
Bicuspid...30-50 years
Rheumatic...30-60 years
Degenerative...60+ years
Bicuspid Aortic Valve
Most common congenital cardiac abnormality is bicuspid aortic valve affecting 1-2% of the US Population

Over time, 1/3-1/2 of such valves become stenotic, with significant narrowing of the aortic orifice typically developing in the 5th and 6th decades of life.
What two etiologies should be suspected for a patient in their 4th or 5th decade of life presenting with aortic stenosis?
Bicuspid or Rheumatic
Pathophysiology of aortic stenosis
Increase in after load => vasoconstriction => decrease in systemic and coronary flow from obstruction => progressive hypertrophy => Pulmonary edema => Left heart failure
Aortic stenosis physical findings
Intensity does not predict severity
Presence of thrill DOES NOT predict severity
"Diamond" shaped, systolic crescendo-decrescendo

I<>I I<>I I<>I

Decreased, delay & prolongation of pulse amplitude
Paradoxical S2
S4 (with left ventricular hypertrophy)
S3 (with left ventricular failure)
Aortic Stenosis Triad
Angina with exertion (Not related to breathing)
Syncope due to decreased blood flow
Dyspnea/CHF on exercise
How do you diagnose aortic stenosis?
Echo 2D/color doppler

ECH shoes LAE and LVH
Cardiac Cath is only used when it's necessary to visualize the coronary involvement.
How do you treat aortic stenosis?
Aortic valve replacement in symptomatic patients

Percutaneous aortic balloon valvuloplasy is reserved only for young patients without rheumatic or calcified valves.
Aortic Regurgitation etiologies
Congenital...bicuspid valve
Aortopathy...collagen disorders, ehler-danlos
Acquired...Rheumatic heart disease, HTN, degenerative, connective tissue d/os
Acute AI...aortic dissection, infective endocarditis, trauma
Pathophysiology of Aortic Regurgitation
Strok volume increases (increasing SBP)
Regurgitant volume increases (decreasing DBP)...widening pulse pressure

Decreased DBP = decreased perfusion (decreased supply)
Increased LV size = increased demand
Symptoms of Aortic regurgitation
Dyspnea, orthopnea, PND
Chest pain

Usually asymptomatic until middle age
Peripheral signs of severe aortic regurgitation
Quincke's sign (capillary pulsations)
Corrigan's sign (water hammer pulse)
De Musset's sign (systolic head bobbing)
Mueller's sign (systolic pulsation of uvula)
Hill's sign (BP lower extremity > BP upper extremity)
Physical Exam of Aortic Regurgitation
Widened pulse presure
High pitched, blowing decrescendo diastolic murmur at LSB (best heard leaning forward)

I I> I I> I
Central signs of severe aortic regurgitation
Apex is enlarged, displaced
Palpable S3
Length of murmur correlates with severity
Increased peripheral signs = increased severity
How do you diagnose Aortic Regurgitation?
Echo 2D/color doppler

ECG shows LAE, LVH
Cardiac Cath only used to visualize coronary involvement
How do you treat Aortic Regurgitation?
Aortic Valve Replacement
Mitral Regurgitation etiologies
Valvular leaflets...myxomatous MV disease, Rheumatic, Endocarditis, Congenital clefts
Chordae...fused, torn, degenerative, infectious endocarditis
Annulus...calcification, IE (abscess)
Papillary Muscles...CAD, Infiltrative d/o
LV dilation (functional regurg)
Trauma
Mitral Regurgitation Pathophysiology
Chronic LV volume overload =>LVE (initially able to maintain CO)
Decompensation => CHF
LVE => annulus dilation => Mitral Regurgitation
Back flow => LAE, Afib, Pulmonary HTN
Symptoms of Mitral Regurgitation
Dyspnea, Orthopnea, PND
Fatigue
Pulmonary HTN, right sided failure
Hemoptysis
Systemic embolization in Afib

May be asymptomatic for years or life or may cause left sided heart failure
Physical Exam of Mitral Regurgitation
Holosystolic Apical Blowing Murmur

I>>>I I>>>I I>>>I

Laterally displaced apical impulse
Split S2
S3 gallop (increased volume during diastole)
How do you diagnose Mitral Regurgitation?
Echo 2D/color doppler

ECG shows LAE, LVH
Cardiac cath is only used to visualize coronary involvement
How do you treat Mitral Regurgitation?
Diuretics
Vasodilators
MV replacement
MV repair (preferred to replacement)
2 Types of Mitral Valve Prolapse
20-50 years of age
Low BP, orthostatic hypo., palpitations, chest pain
Mid systolic click, possible systolic murmur
Little progression of disease

40-70 years of age
Thickend MV
Significant leaflet prolapse
Progressive MR, surgery often required
Symptoms of Mitral Valve Prolapse
Majority are asymptomatic for life
Palpitations
Chest pain (often substernal, prolonged, poorly related to exertion, and rarely resembles typical angina)
Syncope
Physical Exam of Mitral Valve Prolapse
Mid to late systolic click

I C>>I I C>>I I C>>I

Occassional whooping or honking at the apex
Complications of Mitral Valve Prolapse
Arrhythmias (usually PVC, PSVT or VT)
Transient cerebral ischemia
Infective endocarditis
Sudden death
Mitral Stenosis etiologies
Primarily a result of rheumatic fever
Scarring and fusion of valve apparatus
Rarely congenital
Mitral Stenosis Pathophysiology
Progresses slowly so most people don't know they have it until it's severe.

LA HTN => pulmonary edema => pulmonary HTN => LA stretch and atrial fib => Limited LV filling and cardiac output
Symptoms of Mitral Stenosis
Fatigue
Palpitations
Cough
SOB
Left sided failure
Afib
Systemic embolism
Pulmonary infection (hemoptysis)
Right sided failure

Condition worsened by pregnancy, exertion, fever, anemia, tachycardia, intercourse, thyrotoxicosis
Physical Exam of Mitral Stenosis
Palpable S1 at apex
RV lift
Palpable S2
ECG shows LAE, afib, RVH, RAD
Loud S1 (as loud as S2 in aortic area)

I I <> <I I <> <I I <> <I
How do you diagnose Mitral Stenosis?
Echo 2D/color doppler

ECG shows Afib, LAE, RAE, RVH
Cardiac cath is only used to visualize coronary involvement
Complications of mitral stenosis
Atrial dysrrhythmias
Systemic embolization
CHF
Pulmonary infarcts
Hemoptysis
Endocarditis
Pulmonary infections
How do you treat Mitral Stenosis?
Diuretics for LHF/RHF
Balloon valvuloplasty