Cardiac Cycle: Heart Murmurs

Mary Beth Fontana MD

Block Objectives
Describe the mechanisms of production of cardiac murmurs and vascular bruits Describe how cardiac murmurs are characterized; relate to the cardiac cycle and cardiothoracic relationships Distinguish between normal and abnormal heart sounds and murmurs Describe how respiratory and positional maneuvers can enhance cardiac diagnosis

Objectives- murmurs
Describe systolic, diastolic, and continuous murmurs and give etiologies

Resources
Lilly 5th edition;
Chapter 2 pp. 36-43 Blaufuss.org:Heart Sound Tutorial & Quiz

CSEAC: Interactive Cardiac Exam & Physiologic Origins of Heart Sounds and Murmurs (CD used in lecture)

CSEAC Access
Fill out a reservation form at the link: http://medicine.osu.edu/orgs/clinicalskills/p rocedural request form/pages/index.aspx In the Clinical Skills Centers 6th floor small group debriefing rooms After completing the form, will be contacted in 2-3 days to schedule time Plan ahead

Heart murmurs
Audible prolonged sounds generated by turbulent blood flow

Laminar and Turbulent Flow

Laminar (streamline) flow = different layers of molecules move parallel to each other
Laminar flow Turbulent flow

Reynolds number

Re = Vdp/
V mean velocity; d diameter; p fluid density; - fluid viscosity Re > 2,000 (for homogeneous fluids)
Changes in velocity of flow or diameter of a vessel or valve are the usual causes of murmurs and bruits

Flow

Pressure

Mechanisms of Murmurs
#1 Flow across partial obstruction

#2 Increased flow across normal structures #3 Ejection into a dilated vessel #4 Regurgitant flow across incompetent valve #5 Abnormal communication between high and low pressure chambers or vessels

#1 Flow Across Partial Obstruction

Heart valve that doesnt open completely when it should called stenosis Narrowing of outflow from the heart by excessive muscle in a ventricle Localized narrowing of a blood vessel aorta, pulmonary artery, peripheral vessel A murmur over a peripheral vessel is called a BRUIT

#2 Increased Flow Across Normal

Structures
Increased stroke volume and/or rapidity of ejection of blood by the ventricles Many causes are physiologic
Children Slow heart rates Exercise Pregnancy

Pathologic anemia, Congenital heart disease atrial septal defect

#3 Ejection Into Dilated Vessel

Least common cause Dilation of the proximal aorta or pulmonary artery from whatever cause

#4 Abnormal Flow When a Valve

Doesnt Close
Aortic & pulmonic valves should be closed during diastole Mitral and tricuspid valves should be closed during systole Turbulent flow from the leaking valve is driven by higher pressure on one side of the valve

Normal Cardiac Cycle

RA (2-8) RV 30/2-8 PA 30/12 LA (2-12) LV 140/2-12 AO 140/90

#5 Abnormal Communication Between High and Low Pressure Chambers or Vessels

Result of a congenital defect
Between ventricles ventricular septal defect Between aorta and pulmonary artery- patent ductus arteriosus

Normal Cardiac Cycle

RA (2-8) RV 30/2-8 PA 30/12 LA (2-12) LV 140/2-12 AO 140/90

Description of Murmurs
Timing systolic, diastolic, continuous Intensity Grade I-VI systolic Grade I-IV diastolic Pitch or frequency high if large pressure difference between chambers or vessels, low if small pressure difference Shape or configuration crecendodecrescendo or decrescendo

Description of Murmurs
Location maximum intensity closest to source use anatomic landmarks Quality harsh, blowing, musical Radiation in direction of turbulent blood flow Response to maneuvers position change, respiration

Normal Cardiac Cycle

RA (2-8) RV 30/2-8 PA 30/12 LA (2-12) LV 140/2-12 AO 140/90

Systolic Murmurs

Systolic Ejection Murmur

Pathologic - #1 partial obstruction to flow aortic or pulmonic stenosis Crescendo- decrescendo- which parallels the increased flow during early ventricular ejection with decreased pressure and flow later in systole. Always a gap between S1 and beginning of murmur(isovolumic contraction time) and the murmur ends before respective second sound(A2 or P2) Grade III/VI or greater in intensity Many frequencies, often harsh, so heard with the diaphragm and bell Best heard 2 RSB for AS; 2LSB for PS AS radiates to the carotids

Systolic Ejection Murmur

Physiologic--#2 increased flow across normal structures called innocent or functional Usually grade I-II/VI in intensity Best heard in the aortic or pulmonary area Decrease in intensity in upright position

Systolic Ejection Murmur

Parallels rapid early ventricular ejection and reduction of flow later in systole

S1

S2

Pansystolic Murmur
Mechanisms #4 & #5 Begin with S1 and continue to S2. There is a large pressure difference between chamber of origination and the chamber into which the abnormal flow occurs throughout systole.
Between LV and LA in mitral regurgitation(MR) Between RV and RA for tricuspid regurgitation(TR) Between LV and RV for ventricular septal defect(VSD)

High pitched so best heard with the diaphragm

At apex for most MR At LLSB for TR At LSB for VSD

Pansystolic murmur
Large pressure difference between chambers throughout systole

S1

S2 Start with S1 and continue to S2

Late Systolic Murmur

#4 Abnormal Flow When a Valve Doesnt Close Systolic prolapse of mitral leaflet(s) maximum prolapse occurs in mid-late systole with mild prolapse, so regurgitation occurs late. Often preceded by one or more nonejection clicks

Late Systolic Murmur

With mild mitral leaflet prolapse the valve doesnt leak until late systole

S1

S2

Diastolic Murmurs

Diastolic Decrescendo Murmur

#4 Abnormal Flow When a Valve Doesnt Close aortic regurgitation, pulmonic regurgitation with severe pulmonary hypertension high pitched due to large vessel ventricular pressure difference during diastole decrescendo because the pressure difference gradually decreases begin with the S2 component (A2 or P2) both best heard at left sternal border with the diaphragm

Diastolic Decrescendo Murmur

Aortic regurgitation the murmur starts with A2. Intensity drops as aorta-LV pressure difference decreases during diastole

S1

S2

Mid-Late Diastolic Murmur

#1 Flow across partial obstruction mitral, tricuspid stenosis Gap from S2 to murmur beginning due to isovolumic relaxation; opening snap of AV valve initiates murmur Presystolic accentuation when atrial contraction increases the velocity of flow across the valve low pitched due to small pressure difference between atrium and ventricle. Often called rumbles Best heard with the bell at apex in the left lateral position for mitral stenosis; LLSB for tricuspid stenosis

Mid-Late Diastolic Murmur

Mitral stenosis murmur begins with mitral valve opening and accentuates with atrial contraction

OS

S2

S1

P wave indicates sinus rhythm

Middiastolic Low Pitched Murmur

#4 pulmonic valvular regurgitation with normal pulmonary artery pressure; best heard at LSB with the bell #2 high early diastolic flow across mitral or tricuspid valves as in severe mitral, tricuspid regurgitation; best heard at apex for mitral, LLSB for tricuspid with the bell #1 preclosure of mitral leaflets by severe aortic regurgitation (Austin Flint)

Middiastolic Murmur
If severe mitral, tricuspid regurgitation, early diastolic flow into the ventricle is markedly increased

S2

S1

Continuous Murmur
#5 Any communication between high pressure and lower pressure where the pressure difference persists from systole into diastole. Blood flow always in one direction Patent Ductus Arteriosus between aorta and pulmonary artery Continuous does not necessarily mean that murmur never stops; only that it starts in systole and spills over S2 well into diastole, usually peaking around S2. Usually multifrequency so can be heard with diaphragm or bell. PDA murmur can be quite loud and has been called a machinery murmur. Heard best at the upper left sternal border

Continuous Murmur
Any communication between systemic and pulmonary circulations- large pressure difference throughout cardiac cycle turbulent flow always in one direction as in patent ductus arteriosus

S1

S2

Continuous Murmur
If downstream pressure is elevated, the later diastolic component may not be audible as in pulmonary hypertension with a PDA

S1

S2

To and Fro Murmurs

To and Fro Murmurs

#1, #4 any combination of stenosis and regurgitation at any cardiac valve.
there is a gap between the systolic (to) and diastolic (fro)murmurs since blood flow has to change direction murmurs tend to have different pitch, configuration, and quality

To and Fro Murmurs

Stenosis and regurgitation of a cardiac valve blood flow has to change direction

S1

S2

This example is aortic stenosis and regurgitation

Thrills & Bruits

Thrill palpable vibration felt where a murmur is loudest and of Grade IV or more intensity Bruit - an audible murmur over a peripheral vessel

Maneuvers
Respiratory variation right sided murmurs increase with inspiration Postural change standing and squatting change ventricular volume Leg raising increases right heart murmurs immediately Isometric handgrip raises arterial pressure Variation in R-R interval- ejection murmurs accentuate after long R-R interval, regurgitant murmurs do not

Summary
Describe all characteristics of a murmur Judge the significance of a murmur by the rest of the history and physical findings Systolic murmurs can be benign or pathologic; diastolic pathologic The H & P makes most cardiac diagnoses