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30 Cards in this Set

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Many murmurs are ______ murmurs without valvular pathology.
Many murmurs are FLOW murmurs without valvular pathology.
Flow murmurs are benign, short (systolic/diastolic) murmurs that are 1-2/6 in intensity, are loudest at the _____________ , do not radiate to the neck and do not cause symptoms.
Flow murmurs are benign, short SYSTOLIC murmurs that are 1-2/6 in intensity, are loudest at the UPPER STERNAL BORDER, do not radiate to the neck and do not cause symptoms.
What groups of people often have flow murmurs?
1. Athletes
2. Patients with anemia
3. Fever
4. Hyper thyroidism
Systolic murmurs are more likely pathologic if intensity is greater than _____ out of 6, radiate to the _________ , are present in people older than age _____ , or are accompanied by cardiac or pulmonary symptoms.
Systolic murmurs are more likely pathologic if intensity is greater than 4 out of 6, radiate to the CAROTIDS, are present in people older than age 55, or are accompanied by cardiac or pulmonary symptoms.
T or F: A diastolic murmur is ALWAYS pathologic.
True
What are common causes of systolic murmurs?
1. Flow murmurs
2. Aortic Stenosis (AS)
3. Mitral regurgitation (MR)
4. Hypertrophic cardiomyopathy
Aortic stenosis is most commonly due to:

1.
2.
Aortic stenosis is most commonly due to:

1. Calcification of a congenital bicuspid valve (age less than 55)
2. Degenerative valvular disease (age greater than 55)
Aortic stenosis due to rheumatic heart disease occurs in people 40-60 years old, about ____ years after acute rheumatic fever.
Aortic stenosis due to rheumatic heart disease occurs in people 40-60 years old, about 15 years after acute rheumatic fever.
Aortic ___________ is a calcification of the aortic valve found in older individuals that can cause a murmur similar to aortic STENOSIS. Aortic _______ can evolve into AS after time.
Aortic SCLEROSIS is a calcification of the aortic valve found in older individuals that can cause a murmur similar to aortic STENOSIS. Aortic SCLEROSIS can evolve into AS after time.
A cause of systolic murmur is obstruction of the LV outflow tract with ___________ .
A cause of systolic murmur is obstruction of the LV outflow tract with HYPERTROPHIC CARDIOMYOPATHY.
Hypertrophic cardiomyopathy (HCM) is a genetic disease that causes _____________ . HCM has been the underlying cause of sudden death in some famous athletes and should be ruled-out in any sports physical.
Hypertrophic cardiomyopathy (HCM) is a genetic disease that causes SYNCOPE WITH EXERTION. HCM has been the underlying cause of sudden death in some famous athletes and should be ruled-out in any sports physical.
What are the key causes of diastolic murmurs?
1. Aortic regurgitation
2. Mitral stenosis
Aortic regurgitation (AR) can occur with:

1.
2.
3.
4.
5.
Aortic regurgitation (AR) can occur with:

1. congenital bicuspid valves
2. rheumatic heart disease
3. endocarditis
3. ankylosing spondylitis
4. rheumatoid arthritis
5. aortic root dilatation/dissection: Marfan's syndrome, aortitis (syphilis, vasculitis).
Mitral stenosis (MS) is often caused by ______________ .
Mitral stenosis (MS) is often caused by RHEUMATIC HEART DISEASE.
My patient has a murmur. How should I proceed?
1. Place the murmur in systole or diastole by palpating pulse
2. Grade the murmur on a scale of one to six
3. Describe pitch, location and sites of radiation (carotids, chest wall sites).
How do I differentiate between the systolic murmurs of AS and MR?

Specific valvular abnormalities are often identifiable by the location and character of the murmur.

AS is diamond-shaped (crescendo-decrescendo), heard best at the ________ and radiates to the _________ .

MR is _________, heard at the _________ and radiates to the __________ .
AS is diamond-shaped (crescendo-decrescendo), heard best at the BASE and radiates to the CAROTIDS.

MR is HOLOSYSTOLIC, heard at the APEX and radiates to the AXILLA.
Severe AS damps and delays the carotid pulse. This is called _________ .
Severe AS damps and delays the carotid pulse. This is called PULSUS PARVUS ET TARDUS.
To differentiate between the murmurs of AS and MR from HCM, auscultate the heart while the patient abruptly stands from squatting or sitting, which decreases venous return. With this maneuver, AS and MR murmurs __________ as stroke volume decrease the amount of blood rushing past the valves.

However, in HCM, the murmur intensity ________ as the thickened outflow tract walls collapse toward one another with the stroke volume decrease.
To differentiate between the murmurs of AS and MR from HCM, auscultate the heart whil the patient abruptly stands from squatting or sitting, which decreases venous return. With this maneuver, AS and MR murmurs DECREASE as stroke volume decrease the amount of blood rushing past the valves.

However, in HCM, the murmur intensity INCREASE as the thickened outflow tract walls collapse toward one another with the stroke volume decrease.
How do the clinical presentations of the systolic murmur conditions differ?

For both AS and MR, a long asymptomatic period may precede LV failure, which then causes fatigue, dyspnea on exertion, orthopnea.

AS typically occurs in older patients and causes syncope and chest pain. Exertional syncope occurs due to fixed __________ in the setting of increased oxygen demand and vasodilation. Chest pain occurs due to poor coronary artery perfusion in ____________ .

MR may present acutely if myocardial infarction causes a rupture _________ muscle.

HCM usually occurs in _________ patients with a family history of an autosomal dominant inheritance pattern of early cardiac problems, though incomplete penetrance may decrease the number of affected family members. Patients may experience few symptoms before a sudden cardiac arrest/event. They may experience exercise intolerance, often masked by avoidance of exercise.
AS typically occurs in older patients and causes syncope and chest pain. Exertional syncope occurs due to fixed CARDIAC OUTPUT in the setting of increased oxygen demand and vasodilation. Chest pain occurs due to poor coronary artery perfusion in DIASTOLE.

MR may present acutely if myocardial infarction causes a rupture PAPILLARY muscle.

HCM usually occurs in YOUNGER patients with a family history of an autosomal dominant inheritance pattern of early cardiac problems, though incomplete penetrance may decrease the number of affected family members. Patients may experience few symptoms before a sudden cardiac arrest/event. They may experience exercise intolerance, often masked by avoidance of exercise.
How can I differentiate between diastolic murmurs of AR and MS?

The early diastolic, high-pitched descrecendo murmur of AR heard maximally in the _____________ with radiation down the _____________ . It almost mimics a breath sound. A ________ pulse pressure often accompanies a pulse with a rapid rise and fall. Use a diaphragm and have the patient lead forward with his or her breath held.

In contrast, the MS murmur is low-pitched, mid-diastolic, and heard at the _______ . A presystolic crescendo is often heard as the atrial kick sends blood across the stenotic mitral valve. Use a lightly placed (BELL OR DIAPHRAGM) over the apex, or in the axilla, and ask the patient to lie in the left lateral decubitus position to best hear the murmur of MS.
The early diastolic, high-pitched descrecendo murmur of AR heard maximally in the SECOND RIGHT INTERCOASTAL SPACE with radiation down the LEFT STERNAL BORDER. It almost mimics a breath sound. A WIDE pulse pressure often accompanies a pulse with a rapid rise and fall. Use a diaphragm and have the patient lead forward with his or her breath held.

In contrast, the MS murmur is low-pitched, mid-diastolic, and heard at the APEX. A presystolic crescendo is often heard as the atrial kick sends blood across the stenotic mitral valve. Use a lightly placed BELL over the apex, or in the axilla, and ask the patient to lie in the left lateral decubitus position to best hear the murmur of MS.
Your stethoscope (bell vs. diaphgragm)
High frequency sounds or murmurs (for example, splitting of sounds, opening snaps, aortic diastolic murmurs) are easier to hear with the diaphragm. The bell, which should be applied lightly to the chest, transmits low frequency sounds more effectively-for example, diastolic murmur of mitral stenosis and third and fourth heart sounds. For routine examination of the heart you should use both the bell and diaphragm. The diaphragm is usually adequate for examination of the chest and abdomen.
How do the clinical presentations of the diastolic murmur conditions differ?

Both AR and MS can have long asymptomatic periods. AS eventually causes symptoms of ______________ by way of increase LV work.

The increased left atrial pressures from MS eventually can cause left atrial enlargement, atrial fibrillation, pulmonary congestion, and ______________. Occasionally, patients with MS present with hemoptysis.
Both AR and MS can have long asymptomatic periods. AS eventually causes symptoms of LEFT HEART FAILURE by way of increase LV work.

The increased left atrial pressures from MS eventually can cause left atrial enlargement, atrial fibrillation, pulmonary congestion, and RIGHT HEART FAILURE. Occasionally, patients with MS present with hemoptysis.
Which patients need an echo or EKG?
Obtain both tests for murmurs with pathologic features:

1. systolic murmur grade 3/6 or greater
2. age older than 55
3. any diastolic murmur
4. concurrent cardiopulmonary symptoms.
How should I manage a patients with pathologic valvular disease?

All patients with pathologic valvular disease need close follow-up to detect onset of heart failure. Review cardiopulmonary symptoms and exam annually. Obtain an echo annually in patients with severe lesions, and every 2-5 years in mild to moderate AS patients, or whenever patients report ___________ cardiopulmonary symptoms.
All patients with pathologic valvular disease need close follow-up to detect onset of heart failure. Review cardiopulmonary symptoms and exam annually. Obtain an echo annually in patients with severe lesions, and every 2-5 years in mild to moderate AS patients, or whenever patients report NEW OR CHANGING cardiopulmonary symptoms.
How should I manage a patients with pathologic valvular disease?

Patients with AR benefit from afterload reducing agents (_______ , _______ and _______ ) to increase cardiac output. These drugs can postpone or avoid surgery in asymptomatic patients with severe regurgitation.
Patients with AR benefit from afterload reducing agents (ACEI,HYDRALAZINE and NIFEDIPINE) to increase cardiac output. These drugs can postpone or avoid surgery in asymptomatic patients with severe regurgitation.
How should I manage a patients with pathologic valvular disease?

Atrial fibrillation is a common complication of atrial enlargement from MS or MR. Atrial fibrillation requires ______________ , cardioversion, and/or heart rate control (_______ , _______ , or _________ ). Refer asymptomatic patients for consideration of valve replacement when there are signs of LV dysfunction, an ejection fraction less than _________, or LV end systolic measurement greater than 45 mm for MR, and greater than 55 mm for AR.

Refer all patients with cardiopulmonary symptoms.
Atrial fibrillation is a common complication of atrial enlargement from MS or MR. Atrial fibrillation requires ANTICOAGULATION (WARFARIN), cardioversion, and/or heart rate control (BETA-BLOCKERS , CCB, or DIGOXIN). Refer asymptomatic patients for consideration of valve replacement when there are signs of LV dysfunction, an ejection fraction less than 55%-60%, or LV end systolic measurement greater than 45 mm for MR, and greater than 55 mm for AR.
How should I manage a patients with pathologic valvular disease?

Acute AR or MR resulting from aortic dissection (AR), endocarditis (AR and MR) and myocardial infarction (MR) require ___________ to avoid LV failure.
Acute AR or MR resulting from aortic dissection (AR), endocarditis (AR and MR) and myocardial infarction (MR) require URGENT VALVE REPLACEMENT to avoid LV failure.
Are there any special issues in managing patients with MS?
Diuretics can reduce pulmonary congestion. In patients with atrial fibrillation, rate control and/or cardioversion will markedly decrease symptoms. Systemic embolic can be a problem with MS and lifelong warfarin is begun after any atrial fibrillation.

Consider surgery for limiting dyspnea, uncontrollable pulmonary edema, recurrent systemic emboli on anticoagulation, and severe pulmonary hypertension with right ventricular hypertrophy and hemoptysis.

Open mitral commissurotomy and percutaneous balloon valvuloplasty can be considered for nonregurgitant valves. Regurgitant or distorted valves require replacement.
How can I prevent endocarditis?

Give high-risk patients (those with prosthetic valves, damaged native valves) a single 2 gm oral dose of ________ prior to dental, respiratory tract, or esophageal procedures, and _____________ for genitourinary or gastrointestinal procedures.

Give moderate risk patients (e.g., acquired valvular dysfunction or mitral valve prolapse with regurgitation) ___________ or oral, pulmonary, GI, and GU procedures.
Give high-risk patients (those with prosthetic valves, damaged native valves) a single 2 gm oral dose of AMOXICILLIN prior to dental, respiratory tract, or esophageal procedures, and AMPICILLIN PLUS GENTAMYCIN for genitourinary or gastrointestinal procedures.

Give moderate risk patients (e.g., acquired valvular dysfunction or mitral valve prolapse with regurgitation) AMOXICILLIN or oral, pulmonary, GI, and GU procedures.
Grading Cardiac Murmurs

Grade and Description
1: Cannot hear at first
2: Hear right away, not too loud
3: Loud but no palpable thrill
4: Loud and associated with palpable thrill
5: Heard with stethoscope angled on chest
6: Heard with stethoscope off chest