MS

Causes Rheumatic (>95%) Congenital

Pathophysiology Symptoms LA enlargement Palpitation (AF) Dyspnea LALV flow (diastolic)

Peripheral signs AF

Murmur

Apex

HS

Small volume pulse +/AF

Opering snap Rumbling, low-pitched, middiastolic murmur at apex (louder on expiration, Left lateral position

Tapping (palpable 1st HS), undisplaced apex (pressure overload)

Loud S1

Pulmonary HT

Chest pain

JVP: prominent a wave Lt parasternal heave Malar flush Crepitations, pulmonary edema, effusions Edema, ascites,JVP Symptoms Peripheral sign Systolic thrill

[longer duration of diastolic murmur, closeness of opening snap to 2nd HS more severe MS]

Loud P2

Pulmonary congestion CO Rt heart failure Causes Mitral valve prolapse Rheumatic heart

Cough Fatigue

MR

Pathophysiology LVLA backflow (systolic)

LV dilatation (coronary artery disease, cardiomyopathy) IE MI papillary muscle dyf(x)

Murmur Pan-systolic murmur (apex, radiate to axilla)

Apex

Heart sound - Absent/ Soft S1 - S3 (rapid LV filling in early diastole)

LA enlargement LV dilatation Pulmonary HT

Palpitation (AF)

AF Cardiomegaly Lt parasternal heave

Displaced, diffuse, hyperdynamic apex (vol .overload) Loud P2

Pulmonary venous Dyspnea congestion Fatigue Fatigue CO Rt heart failure Edema, ascites Pathophysiology Symptoms RVRA backflow (systolic) Venous Edema, hepatic congestion enlargement Peripheral signs JVP: giant v waves (cv wave)atrial filling Pulsatile liver Murmur Apex Pansystolic murmur (LLSB, accentuated on inspiration;on expiration) HS normal / soft S1 (if murmur); S2 may be split (loud P2 in pulmonary

TR

Causes RV dilatation (2O to chronic Lt heart failure) Rheumatic

 Infective Endocarditis Pulmonary HT (eg cor

pulmonale/ ASD)
Causes AR Marfan Ankylosing Spondylitis, RA

RV dilatation forward flow RV failure Tiredness JVP, ascites, peripheral edema

Peripheral signs

Usu coexisting MR, MV/AV disease

Murmur

Displaced if co-exist MR

hypertension),.+/- RV 3rd HS (S3) at sternum in RV dysf(x)- induced HF

Apex HS Loud A2

Pathophysiology AorticLV backflow stroke volume

Symptoms

Congenital
bicuspid aortic valve Syphilis (rare)

Palpitation/ awareness of heartbeat

Collapsing pulse, Bounding pulse Wide pulse pressure (BP) [>60mmHg]

Dilated aortic
root- aortic dissection, Marfan Causes Rheumatic Calcified biscupid aortic valve Degenerative calcification Pathophysiology Symptoms LV hypertrophy LV hypertrophy Lt heart failure SOB, angia

Corrigans sign: carotid pulsation Quinckes sign: capillary pulsation in nail bed De Mussets sign: head nodding Duroziezs sign: femoral bruit (pistol shot) Argyll Robertson pupils (Syphilis)

High-pitched early diastolic murmur (Lt sternal border, expiration + lean forward) Austin-Flint murmur (middiastolic/ presystolic murmur low-pitched rumbling murmur best at apex) a/w severe ARmitral valve displacement + Turbulence of blood (LALV + aortaLV) (vol .overload) Displace apex

S4

Peripheral signs

Murmur Systolic ejection click Ejection systolic murmur (aortic & Lt sterna edge, full expiration+ lean forward), radiate to neck (2 sides)

AS

Outflow

obstruction (LVaorta flow) HR for CO

Exertional : 1. Dyspnea 2. Chest pain 3. Syncope

small vol, slow-rising pulse,

narrow pulse pressure Carotid pulse: slow rising

Apex undisplaced apex (sustained + thrusting)

HS Soft 2nd HS (A2) if more severe/ calcified

Aortic systolic thrill

Systolic heart murmur 1. Mid-systolic ejection due to blood flow thro semilunar valves; occur at start of blood ejection (after S1) ends with cessation of blood flow (before S2). so onset of mid-systolic ejection murmur is separated from S1 by the isovolumic contraction phase; the cessation of the murmur and the S2 interval is the aortic or pulmonary hangout time. The resultant configuration of this murmur is a crescendo-decrescendo murmur. Causes: outflow obstruction, increased flow through normal semilunar valves, dilation of aortic root or pulmonary trunk, or structural changes in the semilunar valves without obstruction. Condition Description

Aortic outflow obstruction

DDx: AS, hypertrophic cardiomyopathy (HCM), with a harsh and rough quality. **Valvular aortic stenosis: - harsh/ even a musical murmur over right 2nd intercostal space, radiates to neck; heaving apical impulse. - most common cause - calcified valves due to aging; 2nd common cause: congenital bicuspid aortic valves. difference between these 2 causes: bicuspid AS has little or no radiation. It can be confirmed if it also has an aortic ejection sound, a short early diastolic murmur, and normal carotid pulse. The murmur in valvular AS decreases with standing and straining with Valsalva maneuver. ** Supravalvular AS: loudest at a point slightly higher than in that of valvular AS;may radiate more to right carotid artery. **Subvalvular AS: usu due to hypertrophic cardiomyopathy (HCM), with murmur loudest over left sternal border/ apex. The murmur in HCM increases in intensity with a standing position as well as straining with Valsalva maneuver. - A harsh murmur on left second intercostal space radiating to left neck + palpable thrill - distinguished from a VSD by listening to the S2, which is normal in VSD but it is widely split in pulmonary stenosis. However, VSD is almost always pansystolic where the murmur of pulmonary stenosis is diamond-shaped and ends clearly before S2. Many innocent

Pulmonic outflow obstruction

murmurs also arise from this location but S1 and S2 must split normally. Dilation of aortic root or Produces an ejection sound, with a short ejection systolic murmur and a relatively wide split S2. There is no hemodynamic abnormality. pulmonary artery This is similar to pulmonary hypertension except the latter has hemodynamic instabilities. Increased semilunar This can occur in situations such as anemia, pregnancy, or hyperthyroidism. blood flow Aortic valve sclerosis This is due to degenerative thickening of the roots of aortic cusps but produces no obstruction and no hemodynamic instability and thus should be differentiated from aortic stenosis. It is heard over right second intercostal space with a normal carotid pulse and normal S2. Innocent midsystolic These murmurs are not accompanied by other abnormal findings. One example of a benign paediatric heart murmur is Still's murmur in murmurs children. 2. Late systolic starts after S1, extends up to S2 in left sided, usu in crescendo manner. Causes: mitral valve prolapse, tricuspid valve prolapse and papillary muscle dysf(x). Condition Description Mitral valve prolapse - heard best over apex, usually preceded by clicks. - The most common cause of MVP is "floppy" valve (Barlow's) syndrome. If the prolapse becomes severe enough, mitral regurgitation may occur. Any maneuver that decreases left ventricular volume such as standing, sitting, Valsalva maneuver, and amyl nitrate inhalation can produce earlier onset of clicks, longer murmur duration, and decreased murmur intensity. Any maneuver that increases left ventricular volume such as squatting, elevation of legs, hand grip, and phenylephrine can delay the onset of clicks, shorten murmur duration, and increase murmur intensity. Tricuspid valve prolapse Uncommon without concomitant mitral valve prolapse. Best heard over left lower sternal border. Papillary muscle dysf(x) Usually due to acute myocardial infarction or ischemia, which causes mild mitral regurgitation.

3. Holosystolic (pansystolic) start at S1 and extends up to S2. usually due to regurgitation eg mitral regurgitation, tricuspid regurgitation, or ventricular septal defect (VSD) Condition Description Tricuspid Intensifies upon inspiration; best heard over 4th left sternal border. The intensity accentuated following inspiration (Carvallo's sign) due to insufficiency increased regurgitant flow in right ventricular volume. Tricuspid regurgitation is most often secondary to pulmonary hypertension. Primary tricuspid regurgitation is less common and can be due to bacterial endocarditis following IV drug use, Ebstein's anomaly, carcinoid disease, or prior right ventricular infarction. Mitral No intensification upon inspiration. In MR, the pressure in the L ventricle becomes greater than that in the L atrium at the onset of isovolumic regurgitation contraction, which corresponds to the closing of the mitral valve (S1) murmur in MR starts at the same time as S1. This difference in pressure extends throughout systole and can even continue after the aortic valve has closed, explaining sometimes drown the sound of S2. The murmur in MR is high pitched;l best heard at apex with diaphragm of the stethoscope with patient in the lateral decubitus position. Left ventricular function can be assessed by determining the apical impulse. A normal or hyperdynamic apical impulse suggests good ejection fraction and primary MR. A displaced and sustained apical impulse suggests decreased ejection fraction and chronic and severe MR. Ventricular septal No intensification upon inspiration. VSD produce a shunt between the left and right ventricles. Since the L ventricle has a higher pressure defect than the R ventricle, flow during systole occurs from the L to R ventricle, producing the holosystolic murmur. It is best heard over left 3rd and 4th intercostal spaces and along the sternal border. It is associated with normal pulmonary artery pressure and thus S2 is normal. This fact can be used to distinguish from pulmonary stenosis, which has a wide splitting S2. When the shunt becomes reversed ("Eisenmenger syndrome"), the murmur may be absent and S2 can become markedly accentuated and single. Diastolic murmurs - start at or after S2 and end before or at S1; Many involve stenosis of the atrioventricular valves or regurgitation of the semilunar valves. 1. Early diastolic start at the same time as S2 with the close of the semilunar (aortic & pulmonary) valves and typically end before S1. Common causes include aortic or pulmonary regurgitation and left anterior descending artery stenosis. Condition Description Aortic The murmur is low intensity, high-pitched, best heard over the left sternal border or over the right second intercostal space, especially if the regurgitation patient leans forward and holds breath in full expiration. The radiation is typically toward the apex. The configuration is usually decrescendo and has a blowing character. The presence of this murmur is a good positive predictor for AR and the absence of this murmur strongly suggests the absence of AR. An Austin Flint murmur is usually associated with significant aortic regurgitation. 2. Mid-diastolic - start after S2 and end before S1. They are due to turbulent flow across the atrioventricular (mitral & tricuspid) valves during the rapid filling phase from mitral or tricuspid stenosis. Condition Description Mitral stenosis This murmur has a rumbling character and is best heard with the bell of the stethoscope in the left ventricular impulse area with the patient in the lateral decubitus position. It usually starts with an opening snap. In general, the longer the duration, the more severe the mitral stenosis. However, this rule can be misleading in situations where the stenosis is so severe that the flow becomes reduced, or during highoutput situations such as pregnancy where a less severe stenosis may still produce a strong murmur. tapping apical impulse

Atrial myxoma Austin Flint murmur 3. Late diastolic

Atrial myxomas are benign tumors of the heart. Left myxomas are far more common than right myxomas and those may cause obstruction of the mitral valve producing a mid-diastolic murmur similar to that of mitral stenosis. An echocardiographic evaluation is necessary. An apical diastolic rumbling murmur in patients with pure aortic regurgitation. This can be mistaken with the murmur in mitral stenosis and should be noted by the fact that an Austin Flint murmur does not have an opening snap that is found in mitral stenosis.

start after S2 and extend up to S1 and have a crescendo configuration. They can be associated with AV valve narrowing. They include mitral stenosis, tricupsid stenosis, myxoma, and complete heart block Time Condition Description Late diastolic (presystolic) Complete heart block A short late diastolic murmur can occasionally be heard (Rytand's murmur).