IM CV murmurs USMLE 2
Terms
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- Heart valve dz almost always due to Rheumatic Fever
- Mitral Stenosis
-
Murmur type:
Dyspnea on Exertion; Cough, rales; signs of RV failure; RV precordial thrust; Hoarse voice -
Mitral Stenosis
(Hoarse voice is from enlarged LA on recurrent laryngeal nerve) -
Diagnostic results for Mitral Stenosis
- Auscultation
- CXR (2)
- EKG (3)
- Echo -
Auscultation: mid-diastolic low-pitched rumble w/ opening snap;
CXR: large Left atrium and Kerely B lines
EKG: LA enlargement; RV hypertrophy; A-fib
Echo: abnormal valve -
Tx for mitral stenosis w/ each grade:
I (4);
II (2);
III/IV (1)
What should always be avoided w/ mitral stenosis tx? -
Grade:
I: Diuretics; B-Blockers; Anticoagulants; Digitalis
II: Drugs from I + Balloon valvuloplasty (if drugs dont work)
III/IV: Balloon Valvuloplasty
Avoid: Inotropic Agents! -
Etiology of Acute Mitral Regurgitation
(2) -
MI w/ papillary muscle rupture;
Endocarditis -
Etiology of Chronic Mitral Regurgitation
(3) -
Rheumatic fever;
Mitral Prolapse;
LV dilation -
Diagnostic tests for Mitral Regurgitation
- Auscultation
- EKG
- Echo -
Auscultation: Loud, holosystolic apical murmur radiating to axilla
EKG: large LA
Echo: valve problem - Tx for Mitral Regurgitation (6)*
-
DAVES Deal:
Diuretics;
ACEi;
Vasodilators;
Endocarditis prophylaxis;
Surgery if severe;
Digitalis - Most common valvular disorder
- Mitral prolapse
- Asymptomatic murmur w/ genetic predisopositon, seen most commonly in women
- Mitral Prolapse
- What (2) murmurs are seen in Marfan's syndrome?
-
Mitral prolapse
Aortic Regurg - Tx for mitral prolapse?
- not necessary to tx unless symptomatic
-
Mean survival rate for patients w/ Aortic Stenosis and:
1. Angina
2. Syncope
3. Heart failure -
1. 5 years
2. 2 - 3 years
3. 1 - 2 years - Etiology of Aortic Stenosis (2)
-
- Calcific dz w/ age
- Bicuspid valve (around age 40) -
Conditions w/ a wide Pulse Pressure
(6)* -
WAH-HA-H-ide pulse pressure:
Wet beri-beri;
Aortic Regurgitation;
Hyperthyroidism;
HTN;
Anemia;
Hypertrophic Subaortic Stenosis (IHSS) -
What (2) valve disorders result in severe decompensation to CHF due to the absence of hemodynamic compensation?
How are they treated? -
Mitral Regurg
Aortic Regurg
Tx: Emergent surgery -
Classic triad* of Sx for Aortic Stenosis
(4) other signs -
SAD:
- Syncope;
- Angina;
- Dyspnea on Exertion
Others:
- Forceful apex beat
- narrow Pulse Pressure
- Paradoxical S2 split
- heard in carotids -
Diagnostic test results for Aortic Stenosis
- Auscultation
- EKG
- Echo
- CXR -
Auscultation: Loud systolic crescendo-decrescendo murmur;
EKG: LV strain
CXR: calcifications on valve
Echo: diseased valve -
What is the EKG LV strain pattern seen in aortic stenosis?
(hint: affects 4 leads) - ST depression + T-wave inversion in I, aVL, V5 and V6
-
Tx for aortic stenosis
What should be avoided?
(2) -
Valve replacement
- AVOID Afterload reducers (ACEi & beta-blockers) - (2) main etiologies for Aortic Regurgitation
-
Aortic root dilatation or dissection;
Valvular dz; - (3)* causes of Aortic root dilatation thereby causing Aortic Regurg
-
Marfan's;
Idiopathic (but inc w/ HTN);
Collagen vascular dz - (2) causes of Valvular dz thereby causing Aortic Regurg
-
Rheumatic heart dz;
Endocarditis - (6)* causes of proximal Aortic root dissection thereby causing Aortic Regurg
-
"THE MTS":
Third Trimester Pregnancy;
HTN;
Ehlers-Danlos;
Marphans (Cystic medial necrosis);
Turner's syndrome;
Syphilis;
(Aortic arch is shaped like a mountain) -
Names of the unique signs of Aortic regurg
(7)* -
Tap Water Quickly Complicates De-Murmur Designs:
1. Traube's sign
2. Water-Hammer pulse
3. Quincke's sign
4. Corrigan's pulse
5. de Musset's sign
6. Muller's sign
7. Duroziez's sign -
Aortic regurg sign:
wide pulse pressure presenting w/forceful arterial pulse upswing w/ rapid falloff - Water-Hammer pulse
-
Aortic regurg sign:
pistol-shot bruit over femoral pulse - Traube's sign
-
Aortic regurg sign:
unusually large carotid pulsations - Corrigan's pulse
-
murmur sign:
pulsatile blanching & reddening of fingernails upon light pressure
What murmur? -
Quincke's sign
(Aortic Regurg) -
Aortic regurg sign:
head bobbing caused by carotid pulsation -
de Musset's sign
(head bobs like listening to "De Mussic") -
Aortic regurg sign:
pulsatile bobbing of the uvula - Muller's sign
-
Aortic regurg sign:
to-and-fro murmur over femoral artery (heard best w/ mild pressure applied to artery) - Duroziez's sign
-
Murmur presentation:
dyspnea, orthopnea, paroxysmal noctournal dyspnea, angina, LV failure, wide pulse pressure - Aortic regurg
-
Murmur presentation:
starts asymptomatic, then dyspnea, angina, syncope, heart failure - Aortic stenosis
-
Murmur presentation:
mostly asymptomatic, atypical chest pain, SOB, fatigue - Mitral Prolapse
-
Murmur presentation:
dyspnea, fatigue, weakness, cough, A-fib, systemic emboli - Mitral Regurg
-
Murmur presentation:
DOE, rales, cough, hemoptysis, systemic emboli, RV precordial thrust, RV failure, Hoarse voice - Mitral stenosis
-
What is heard on Auscultation for Aortic regurg?
(3) -
1. High-pitched, blowing decrescendo diastolic murmur
2. Apical diastolic rumble
(mitral stenosis w/o snap)
3. Midsystolic flow murmur at base -
Tx for Aortic regurg problems
(3) -
Tx LV heart failure;
Endocarditis prophylaxis;
Valve replacement - Etiology of Tricuspid stenosis (3)*
-
CCR:
Congenital;
Carcinoid;
Rheumatic heart dz -
Murmur presentation:
peripheral edema, JVD, hepatomegaly, ascites, jaundice
(2) -
Tricuspid stenosis
or
Tricuspid Regurg -
Auscultation results for Tricuspid stenosis?
Tx? -
Diastolic, rumbling low-pitched heard w/ Inspiration
Tx: Repair valve -
Dx:
Patient w/ DVT has a stroke. He has a fixed S2 split -
Atrial-Septal Defect
(w/ right-to-left emboli) - Etiology of Tricuspid Regurg (4)
-
Increased pulmonary artery Pressure
(from L-CHF or Mitral stenosis/regurg);
R-CHF;
Right papillary muscle rupture w/ MI;
Tricuspid valve lesions
(rheumatic heart or bacterial endocarditis) -
Holosystolic murmurs
(3)* -
MTV
Mitral Regurg;
Tricuspid regurg;
Ventricular Septal Defect - Number 1 cause of death in CHF patients
- Arrhythmia
-
Diagnostic results for Tricuspid Regurg:
- Auscultation
- EKG (2)
- Echo -
Auscultation: Holosystolic murmur increasing w/ inspiration
EKG: RV enlargement; A-fib
Echo: diseased valve -
Tx for Tricuspid Regurg
(3)* -
Tricuspid Dying Slowly:
Tx heart failure;
Diuresis;
Surgical repair of valve - What is done first if a patient has hyperK and peaked T-waves? Why?
- give Calcium to stabilize cardiac membrane
-
Murmur:
Diastolic apical rumble and opening snap - Mitral stenosis
-
Murmur:
Late systolic murmur w/ midsystolic click
What is confirming test? -
Mitral Prolapse
Valsalva - click starts earlier, murmur prolonged -
Murmur:
High-pitched apical blowing holosystolic murmur
where does it radiate? -
Mitral Regurg
radiates: Axilla -
Murmur:
Diastolic rumble louder w/ inspiration - Tricuspid stenosis
-
Murmur:
High-pitched blowing holosystolic murmur heard better w/ inspiration
Where is it heard?
Where are pulsations seen? -
Tricuspid Regurg
- heard at left sternal border
- Jugular pulsations -
Name sign:
Peripheral pulses that are weak and late compared to heart sounds
What murmur? -
Pulsus Parvus et Tardus
Aortic Stenosis -
Murmur:
midsystolic crescendo-decrescendo murmur
Where does it radiate? (2)
What heart sound is also heard? -
Aortic stenosis
radiates to: Carotids and Apex
- S4 also heard -
Name sign:
Double-peaked arterial pulse
what murmur? -
Pulsus Bisferiens
Aortic regurg -
Murmur:
Blowing early diastolic, apical diastolic rumble, midsystolic flow murmurs - Aortic Regurg
-
Dx that causes Murmur:
Systolic murmur at apex and left sternal boarder not transmitted to carotids
How is it heard better? -
IHSS
heard better w/ standing after squat -
When during S1-S2 do you hear the "flow murmur" (murmur heard w/ any high flow state)?
What is differential dx? (5)* -
Midsystolic:
Aortic Regurg
Atrial-Septal defect (fixed split S2)
Anemia
Adolescence
Pregnancy