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72 Cards in this Set
- Front
- Back
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Closing of mitral and tricuspid (AV) valves
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S1
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Heard best at apex, 5th intercostal space
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S1
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Beginning of systole
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S1
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Closing of aortic and pulmonic (semilunar) valves
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S2
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Heard best at base (top of heart)
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S2
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End of systole
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S2
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Sound of rapid filling of the ventricles
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S3
"Sloshing in" Can be normal |
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Normally silent (at apex and at beginning of expiration, best L side lying with bell).
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S3
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Vibration of left ventricle and contraction of atria
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S4
"A Stiff Wall" ABNORMAL |
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Heard best at apex with bell - right before S1
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S4
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Heart sound that indicates possible CAD, Hx of MI, or HTN
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S4
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Systole
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Mitral and tricuspid valves close
Pulmonary and aortic valves open Beats with the pulse |
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Diastole
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Aortic and pulmonary valves close
Mitral and tricuspid valves open Beats before pulse |
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Systolic murmurs
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Aortic stenosis
Pulmonary stenosis Mitral and Tricuspid regurgitation |
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Diastolic murmurs
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Mitral and tricuspid stenosis
Aortic and pulmonary regurgitation |
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Sound of stenosis in systole (A&P)
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Crescendo to decrescendo
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Sound of regurgitation in systole (M&T)
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Plateau (swoosh)
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Sound of stenosis in diastole (M&T)
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Rumble
Plateau + crescendo |
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Regurgitation in diastole (A&P)
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Decrescendo
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These two types of murmurs are typically congenital
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Pulmonary and Tricuspid
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These two types of murmurs are typically acquired after birth
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Aortic and Mitral
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Click
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Sound of aortic and pulmonary valves opening
Heard at the beginning of systole High pitched Does not change with inspiration ABNORMAL |
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Opening snap
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Sound of mitral and tricuspid valves opening
Heard at the beginning of diastole Low pitched Does not change with inspiration ABNORMAL |
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During auscultation, one should use this side of the stethoscope to hear high pitched sounds and murmurs
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Diaphragm
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During auscultation, one should use this side of the stethoscope for low pitched sounds and murmurs
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Bell
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This grade of murmur can only be heard by a cardiologist
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Grade 1
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This grade of murmur is audible after listening for a little while
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Grade 2
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This grade of murmur is audible right away
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Grade 3
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This grade of murmur is associated with a thrill or palpable heart sound
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Grade 4
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This grade of murmur is audible with the stethoscope partially off the chest
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Grade 5
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This grade of murmur is audible at the bed side
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Grade 6
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Innocent murmur
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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) |
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Characteristics of non-innocent murmur
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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 |
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Regurgitation/Insufficiency
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Leaking (back flow) of blood across a closed valve
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Stenosis
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Obstruction of forward flow across an opened valve
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Atrioventricular valves
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Bicuspid (Mitral) and Tricuspid
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Semilunar valves
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Aortic and Pulmonary (Both Tricuspids)
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Spectrum of Valvular heart disease (Left-sided)
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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) |
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Spectrum of valvular heart disease (right-sided)
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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 |
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Aortic stenosis etiologies
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Congenital...0-30 years
Bicuspid...30-50 years Rheumatic...30-60 years Degenerative...60+ years |
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Bicuspid Aortic Valve
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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. |
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What two etiologies should be suspected for a patient in their 4th or 5th decade of life presenting with aortic stenosis?
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Bicuspid or Rheumatic
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Pathophysiology of aortic stenosis
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Increase in after load => vasoconstriction => decrease in systemic and coronary flow from obstruction => progressive hypertrophy => Pulmonary edema => Left heart failure
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Aortic stenosis physical findings
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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) |
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Aortic Stenosis Triad
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Angina with exertion (Not related to breathing)
Syncope due to decreased blood flow Dyspnea/CHF on exercise |
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How do you diagnose aortic stenosis?
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Echo 2D/color doppler
ECH shoes LAE and LVH Cardiac Cath is only used when it's necessary to visualize the coronary involvement. |
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How do you treat aortic stenosis?
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Aortic valve replacement in symptomatic patients
Percutaneous aortic balloon valvuloplasy is reserved only for young patients without rheumatic or calcified valves. |
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Aortic Regurgitation etiologies
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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 |
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Pathophysiology of Aortic Regurgitation
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Strok volume increases (increasing SBP)
Regurgitant volume increases (decreasing DBP)...widening pulse pressure Decreased DBP = decreased perfusion (decreased supply) Increased LV size = increased demand |
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Symptoms of Aortic regurgitation
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Dyspnea, orthopnea, PND
Chest pain Usually asymptomatic until middle age |
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Peripheral signs of severe aortic regurgitation
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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) |
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Physical Exam of Aortic Regurgitation
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Widened pulse presure
High pitched, blowing decrescendo diastolic murmur at LSB (best heard leaning forward) I I> I I> I |
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Central signs of severe aortic regurgitation
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Apex is enlarged, displaced
Palpable S3 Length of murmur correlates with severity Increased peripheral signs = increased severity |
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How do you diagnose Aortic Regurgitation?
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Echo 2D/color doppler
ECG shows LAE, LVH Cardiac Cath only used to visualize coronary involvement |
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How do you treat Aortic Regurgitation?
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Aortic Valve Replacement
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Mitral Regurgitation etiologies
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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 |
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Mitral Regurgitation Pathophysiology
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Chronic LV volume overload =>LVE (initially able to maintain CO)
Decompensation => CHF LVE => annulus dilation => Mitral Regurgitation Back flow => LAE, Afib, Pulmonary HTN |
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Symptoms of Mitral Regurgitation
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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 |
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Physical Exam of Mitral Regurgitation
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Holosystolic Apical Blowing Murmur
I>>>I I>>>I I>>>I Laterally displaced apical impulse Split S2 S3 gallop (increased volume during diastole) |
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How do you diagnose Mitral Regurgitation?
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Echo 2D/color doppler
ECG shows LAE, LVH Cardiac cath is only used to visualize coronary involvement |
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How do you treat Mitral Regurgitation?
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Diuretics
Vasodilators MV replacement MV repair (preferred to replacement) |
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2 Types of Mitral Valve Prolapse
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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 |
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Symptoms of Mitral Valve Prolapse
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Majority are asymptomatic for life
Palpitations Chest pain (often substernal, prolonged, poorly related to exertion, and rarely resembles typical angina) Syncope |
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Physical Exam of Mitral Valve Prolapse
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Mid to late systolic click
I C>>I I C>>I I C>>I Occassional whooping or honking at the apex |
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Complications of Mitral Valve Prolapse
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Arrhythmias (usually PVC, PSVT or VT)
Transient cerebral ischemia Infective endocarditis Sudden death |
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Mitral Stenosis etiologies
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Primarily a result of rheumatic fever
Scarring and fusion of valve apparatus Rarely congenital |
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Mitral Stenosis Pathophysiology
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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 |
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Symptoms of Mitral Stenosis
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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 |
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Physical Exam of Mitral Stenosis
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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 |
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How do you diagnose Mitral Stenosis?
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Echo 2D/color doppler
ECG shows Afib, LAE, RAE, RVH Cardiac cath is only used to visualize coronary involvement |
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Complications of mitral stenosis
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Atrial dysrrhythmias
Systemic embolization CHF Pulmonary infarcts Hemoptysis Endocarditis Pulmonary infections |
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How do you treat Mitral Stenosis?
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Diuretics for LHF/RHF
Balloon valvuloplasty |
