Heart Sounds And Murmurs

Front 1

What are symptoms of low cardiac output?

Back 1

-Dyspnea

-HF symptoms

-Syncope

Front 2

In a female, what are early warning symptoms of acute MI?

Back 2

-Unusual fatigue

-Sleep disturbance

-SOB

-Indigestion

-Anxiety

Front 3

Symptoms reported by women during acute coronary syndrome?

Back 3

-SOB

-Weakness

-Unusual fatigue

-Diaphoresis ("Cold sweat")

-Dizziness

-Chest pain or pressure (30%)

-No chest discomfort during event (43%)

Front 4

ACS in the elder - Clinical presentation ≥ 75 years of age

Back 4

-Dyspnea

-Neurological sxs: syncope, weakness, acute confusion

-Chest pain or pressure (< 50%)

**ACS should be considered a possibility in any acute illness in an elder

Front 5

A healthy adult's heart is roughly....

Back 5

1/3 right heart and 2/3 left heart

Front 6

In which side of the heart are the majority of cardiac problems found?

Back 6

-The left side of the heart is such a high pressure system, attempting to overcome the PVR w/ every heartbeat, the majority of cardiac problems are found in the left side of the heart. Particularly the valvular problems.

Mitral valve disease and Aortic Valve disease are more common than Pulmonic or tricuspid valve disease

Higher pressure L side of heart

Lower pressure R side of heart

Front 7

Normal PMI

Back 7

-Size of impulse = about the area of a nickel

-Location = 5th ICD, MCL

-Sensation = gentle tap by one finger, single impulse

-Time = PMI takes about 1/3 of systole

Front 8

Displaced PMI....

Back 8

-Usually displaced laterally

-Indicates increased LV volume (e.g., LVH)

Front 9

Unusually forceful, sustained PMI....

Back 9

-Pressure overload, HTN

Front 10

Big waves on an ECG indicate...

Back 10

a big left ventricle

Front 11

If you cannot palpate the PMI on a patient, what can you do?

Back 11

Move the patient into the left lateral decubitus position to enhance the PMI

Consider concomitant conditions:

-Thick chest wall (e.g., body builder)

-Obesity

-COPD (Increased A-P diameter)

Front 12

Cardiac Auscultation

Back 12

Front 13

Pathway of blood through the heart

Back 13

Front 14

Heart sounds -

S1

Back 14

-Marks the beginning of systole

-Produced by events surrounding the closure of mitral and tricuspid valve

-Best heard at the apex w/ the diaphragm

-"Lub" of "lub-dub"

-Heard nearly simultaneously with the carotid upstroke

Front 15

Heart sounds -

S2

Back 15

-Marks the end of systole

-Produced by events surrounding the closure of the aortic and the pulmonic valves

-Best heard at the base with diaphragm

-"Dub" of "lub-dub"

*When the HR, < 120 bpm, generally diastole is longer than systole; when HR ≥ 120, Systole and diastole are pretty much the same length

Front 16

Heart sounds -

Physiologic split S2

Back 16

Significance: widening of normal interval between aortic and pulmonic components of the second heart sound. Caused by a delay in the pulmonic component

-Heard best in pulmonic region

-Split increases on patient inspiration

-Found in the majority of adults < age 30, fewer beyond this age

-A benign finding

Front 17

Heart sounds -

Pathologic split S2

Back 17

Significance:

-Fixed split - No change w/ inspiration

-Paradoxical split - narrows or closes on inspiration

-Heard best in pulmonic region

-Fixed split often found in uncorrected atrial septal defect (ASD)

-Paradoxical split often found in conditions that delay aortic closure such as LBBB

-Finding can resolve w/ tx of underlying condition

Front 18

Heart sounds -

Pathologic S3 heart sounds (aka S3)

Back 18

-Marker of ventricular overload and/or systolic dysfunction (part of the pathophysiology of HF)

-Heard in early diastole, can sound like it's "hooked on" to the back of S2

-Low-pitch, best heard w/ bell, might miss w/ diaphragm

-For dx of HF, correlate w/ add'l findings such as dyspnea, tachycardia, crackles

-Finding can resolve w/ treatment of underlying condition

Front 19

Heart sounds -

S4 heart sound

Back 19

-Marker of poor diastolic function, most often in poorly controlled HTN or recurrent MI

-Heard best in late diastole, can sound like it's "hooked on" to the front of S1

-Sometimes called a presystolic sound

-Soft, low-pitch (higher than S3), best heard w/ bell

-Finding can resolve w/ tx of underlying condition

Front 20

Heart valve dysfunction -

Failure to open adequately

Back 20

Stenosis

Front 21

Heart Valve dysfunction -

Failure to close adequately

Back 21

Incompetent - Incompetent valves cause regurgitant murmurs

Front 22

Systolic cardiac murmurs

Back 22

-may be benign or pathologic

-Mitral

-Regurgitation

-Physiologic

-Aortic

-Stenosis

-Systolic

Mitral regurgitation: holosystolic, takes up all of systole and is the same intensity throughout systole

Aortic Stenosis: A crescendo-decrescendo (louder-softer) systolic murmur

Front 23

MR PASS wins the Most Valuable Player Award

Back 23

-Mitral

-Valve

-Prolapse

-Mid- to late-systolic mumur

-Usually preceded by a mid-systolic click

Front 24

Diastolic cardiac murmurs

Back 24

-Always pathologic

-Mitral

-Stenosis

-Aortic

-Regurgitation

-Diastolic

-Mitral stenosis: a later diastolic murmur

-Aortic regurgitation: Earlier diastolic murmur

Front 25

Grading Heart Murmurs - the sound of turbulent blood flow

Back 25

I - very faint

II - Quiet but immediately heard

III - Moderately loud without thrill (about as loud as S1 or S2)

IV - Loud w/ thrill (tremor or vibration on palpation)

V - Very loud with thrill

VI - Audible w/o stethoscope

Front 26

Character of murmurs

Back 26

Harsh: heard well w/ bell & diaphragm (Ex- murmur of aortic stenosis)

Rumble: low, heard best w/ bell (Ex- murmur of mitral stenosis)

Blowing: High, heard best w/ diaphragm (Ex - murmur of aortic regurgitation)

Musical: Vibratory quality (Ex- still murmur [benign childhood murmur])

Front 27

Systolic murmurs - Benign (aka physiologic, flow, functional) or pathologic?

Back 27

Likely benign - consider benign only if all noted:

-Negative hx

-lower grade (≤ Gr III/VI)

-No radiation beyond the precordium (i.e. all over the chest)

-S1, S2 intact

-No heave or thrill

-PMI WNL (5th ICS MCL)

-Soften or disappears w/ supine to stand position change (*Chief characteristic of physiologic murmurs)

*Supine is the preferred position for cardiac auscultation at least to start cardiac exam --> heart is more filled w/ blood than when person is standing; When stand pt up, heart gets taller, thinner, "less fluid in the pump" --> murmur either softens or disappears. Again, this is the chief characteristic of physiologic murmurs

Front 28

Radiating Murmur vs. Carotid Artery Bruit?

Back 28

Carotid Bruit:

-Usually softer

-Often unilateral

-Different sound than that found in chest

Radiating Murmur:

-Usually louder

-Bilateral

-Same sound and timing as found in chest