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Heart murmurs
From WikEM
Contents
Background
Clinical Features
Differential Diagnosis
Valvular Emergencies
Evaluation
Lesions
- Aortic Stenosis
- Systolic murmur heard best in the aortic area; rarely at apex
- Crescendo-decrescendo, radiates to carotids
- A2 decreased
- Paradoxical splitting of S2; narrow pulse pressure
- Pulsus parvus et tardus
- Aortic Insufficiency
- Diastolic blowing murmur heard at left sternal border in 3rd and 4th interspace
- Wide pulse pressure
- Quincke's sign (capillary pulsations at fingertips), DeMusset's sign (bobbing head), Muller's sign (pulsing uvula), and Corrigan's pulse (water hammer)
- Pistol shot sounds
- Pulmonic stenosis
- Systolic murmur heard in pulmonic area, transmitted to back and neck
- A2 is decreased, P2 is delayed, and RVH with parasternal lift
- Pulmonic insufficiency
- High pitched diastolic murmur; heard in pulmonic area; decrescendo; RVH
- Mitral Stenosis
- Low rumbling diastolic murmur heard best at apex with bell
- Opening snap sometimes present worse with closer to S2
- Loud S1
- Associated with left atrial dilation
- Can hear presystolic sound confused with systolic murmur
- Mitral Insufficiency
- Loud, holosystolic, high-pitched, heard best at apex and transmitted to axilla
- Soft S1
- Severity gauged by s3, rumble.
- Paradoxical splitting
Sounds
- Gallavardin Effect
- AS sounds like MR - high frequency vibrations to the apex through a calcific AV
- Austin-Flint
- MS sounds like AR - Soft, rumbling murmur, likely due to functional mitral valve stenosis as the backflow of blood from the aorta presses on anterior leaflet of MV
- Parodoxical S2
- Splittin during expiration and goes away during inspiration
- Secondary to inc left sided volume; AS, HOCM
- Wide S2
- secondary to Inc right sided volume; PE, ASD, VSD, Pulmonic stenosis
- S3
- AKA ventricular gallop produced during passive LV filling when blood strikes a compliant LV; CHF, Inc Vol, CAD, benign in youth, train athletes
- S4
- AKA atrial gallop produced when blood is forced into a stiff/hypertrophic ventricle ;MI, hypertension, restrictive cardiomyopathy
Maneuvers
- Valsalva
- Increases thoracic pressure and lowers preload; then then decreased CO and afterload
- Increases murmur in MP & HOCM
- With release: right heart murmurs return first
- Hand grip
- Increases HR + CO
- Increases murmur in MR, MS, AR
- Decreases murmur in AS and HOCM
- Squatting
- Increased venous return
- Delays MP click
- Standing
- Dec in both right & left venous return & SV
- Decreases murmur of PS, AS, AR, TR, VSD
- Increases murmur of HOCM
- Inspiration
- Increases right sided venous return while decreasing left sided return
- Increases S2 splitting with P2 further from A2
- Increases in right sided S3 & S4
- Increases TS opening snap & murmur, PR, TR
- Decreases MS opening snap, MVP murmur
