71

Patient with SYSTOLIC MURMUR

Confirm timing is systolic

Determine intensity (grade 16) Determine quality (harsh vs. blowing) Determine timing within systole

Identify location of loudest intensity

Left sternal border, 2nd ICS

Right sternal border, g 2nd ICS

Left sternal border, 5th ICS

Mid-clavicular line, 6th ICS

Crescendo-decrescendo

Harsh

Holosystolic Late systolic Harsh quality C Holosystolic click absent click present Crescendodecrescendo Opening click Blowing quality gq y Harsh quality q y Blowing V waves present V waves absent

with Valsalva with p passive leg raise

with Valsalva with p passive leg raise

with inspiration

D
Ventricular septal defect

with handgrip

D
E
Assess for radiation HOCM Radiates to carotids Aortic stenosis No radiation

with inspiration Tricuspid p regurgitation

Click earlier with standing, later with squatting

Pulmonic stenosis

E
Obtain: Echocardiogram Consider: Surgery

Radiates to axilla

F F
Obtain: Echocardiogram Consider: Valvuloplasty

Aortic sclerosis

Mitral prolapse p p with regurgitation

Mitral regurgitation

Obtain: Echocardiogram Consider: Aortic valve surgery

Obtain: Echocardiogram Consider: Medical therapy py Septal reduction

Obtain: Echocardiogram Consider: Medical afterload reduction Mitral valve surgery

or replacement surgery. Tricuspid regurgitation is most often clinically benign but can be repaired if it is both severe and thought to be the cause of heart failure. Pulmonic stenosis is rare in adult patients because it is most frequently a congenital lesion. If detected in the adult, percutaneous valvuloplasty can be curative. Ventricular septal defects in the adult patient occur most commonly as a complication of myocardial infarction. Postmyocardial infarction ventricular septal defects carry a high short-term risk of mortality and should prompt urgent surgical repair.

References
ACC/AHA guidelines for the management of patients with valvular heart disease. J Am Coll Cardiol 1998;32(5):14861588. Chen CR, Cheng TO, Huang T, et al. Percutaneous balloon valvuloplasty for pulmonic stenosis in adolescents and adults. N Engl J Med 1996;335(1):2125. Maron BJ, McKenna WJ, Danielson GK, et al. American College of Cardiology/European Society of Cardiology clinical expert consensus document on hypertrophic cardiomyopathy. A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice Guidelines. J Am Coll Cardiol 2003;42(9):16871713.