Heart murmurs

Kiran Dhaliwal

Contents
Introduction to heart murmurs Normal heart sounds Classification of murmurs Commonest types of valvular disease and associated heart murmurs
Causes Signs and symptoms Investigations and treatment

How to examine a patient with a murmur Quiz

What is murmur?
An abnormal sound heard during the cardiac cycle. (Mayo Clinic) Caused by turbulence of blood flow which occurs when the velocity of the blood is disproportionate to the size of the orifice it is moving through (Cardiology Crash Course)

Normal heart sound

Classification of murmurs

Classification of murmurs

Classicisation of murmurs
Systolic
Ejection systolic Pansystolic

Diastolic
Early distolic Mid-distolic

Continuous

Grading heart murmurs

Ejection systolic murmurs

Cresendo-decresendo systolic murmur

Heart valve pathology

Mitral valve disease
Mitral stenosis Mitral regurgitation

Aortic valve disease

Aortic stenosis Aortic reurgitation

 Causes Signs and symptoms Examination

Pulse Blood pressure Palpation (apex beat) Ausultation

Aortic stenosis
What type of murmur does it produce? What would it look like?

Causes of aortic stenosis

Senile degeneration of aortic valve Rheumatic aortic stenosis Calcification of bicuspid valve Congenital

Signs and symptoms of aortic stenosis

Symptoms Mild or moderate aortic stenosis is usually asymptomatic Sudden death Episodes of acute pulmonary oedema

Triad of symptoms Dizziness SOB Chest pain

Examination
Pulse
Reduced volume Slow rising pulse

Blood pressure
Narrow pulse pressure

Palpitation
Heaving non-displaced apex beat

Ausculatation
Ejection systolic murmur Loudest in aortic region Radiates into the carotids

Aortic regurgitation
Clinical features Collapsing pulse Wide pulse pressure

Austin flint murmur Diastolic murmur High pitched Best heard with

Causes of aortic regurgitation

Signs and symptoms of aortic stenosis

Fatigue Dyspnoea

Examination
Pulse
Large volume Collapsing pulse

Blood pressure
Wide pulse pressure

Palpation
Displaced, heaving apex beat

Auscultation
Early diastolic murmur Blowing High pitched (listen with diaphragm) Loudest in left sternal edge of 4th intercostal space)

Mitral stenosis
Malar flush Atrial fibrilation (if severe) Tapping displaced apex beat

Causes of mitral stenosis

Mitral regurgitation

Causes of mitral regurgitation

Rheumatic fever (50%) SLE Ischemic heart disease Drugs
Appetite suppresants
Fenfluramide

dopamine agonists
Cabergoline

Other types of murmurs

Info included in handout

Examination
Inspection
Scars Heave Hands
Peripheral stigmata of infective endocarditis

Cardiovasular system examination

Pulse Blood pressure JVP

Ausulatation

Auscultation

Examination
Palpation
Thrills

Examination of a patient
Does the patient have any signs of valve disease Does the patient have a murmur
Describe murmur Timing Radiation

Review of patient

10 minutes

1. What murmur is this?

Audio clip

2.
A patient reports SOB on exertion, which gradually becomes more severe PMH: Rheumatic fever as a child On examination they have AF

3. What murmur is this?

Audio clip

4.
On examination a patient has a low volume pulse with a small pulse pressure A systolic thrill is palpable at the apex over the aortic area

5. What murmur is this?

Audio clip

6. What murmur is this?

Audio clip

Summary