Heart Disease Braunwald Chapter 4 Physical Examination (II) --- Heart Murmur --- Heart Murmur Presenter: R4 劉嚴文

Heart DiseaseHeart DiseaseBraunwaldBraunwald

Chapter 4 Physical Examination (II)Chapter 4 Physical Examination (II)

--- Heart Murmur--- Heart Murmur

Presenter: R4 劉嚴文

Cardiac AuscultationCardiac AuscultationHeart MurmurHeart Murmur

Characteristics of heart murmurCharacteristics of heart murmur► TimingTiming in the cardiac cycle in the cardiac cycle► IntensityIntensity (loudness) (loudness)► FrequencyFrequency (pitch) --- (pitch) --- from high to lowfrom high to low

► ConfigurationConfiguration (shape) --- (shape) --- crescendo, decrescendo, crescendo, decrescendo, crescendo-decrescendo (diamond-shaped), plateau (even) or crescendo-decrescendo (diamond-shaped), plateau (even) or variable (uneven)variable (uneven)

► QualityQuality► DurationDuration► DirectionDirection of radiation of radiation



Heart murmurs broad categoriesHeart murmurs broad categories► Systolic:Systolic: begin with / after S1 begin with / after S1

end at / before S2end at / before S2

2 terms out of time 2 terms out of time Regurgitant systolic murmur (holosystolic murmur)Regurgitant systolic murmur (holosystolic murmur) Ejection systolic murmur (midsystolic murmur)Ejection systolic murmur (midsystolic murmur)

► DiastolicDiastolic: : begin with / after S2 begin with / after S2

end at / before the subsequent S1end at / before the subsequent S1

► ContinuousContinuous: : begin in systole and continue begin in systole and continue without inwithout interruption through the S2terruption through the S2 into all / part of diastole into all / part of diastole

Midsystolic MurmursMidsystolic Murmurs

EtiologiesEtiologies► Obstruction to ventricular outflowObstruction to ventricular outflow► Dilatation of the aortic root or pulmonary trunkDilatation of the aortic root or pulmonary trunk► Accelerated flow into the normal aorta or pulmonary tAccelerated flow into the normal aorta or pulmonary t

runk, as during pregnancy, fever, thyrotoxicosis, or anrunk, as during pregnancy, fever, thyrotoxicosis, or anemiaemia

► Innocent (normal) midsystolic murmursInnocent (normal) midsystolic murmurs► Some forms of MRSome forms of MR

Aortic Valve StenosisAortic Valve Stenosis

► Symmetrical diamond shSymmetrical diamond shapeape

► High-velocity jet within tHigh-velocity jet within the aortic roothe aortic root

radiation of the murmur radiation of the murmur upward to the right 2upward to the right 2ndnd in intercostal space and the netercostal space and the neckck

Aortic Valve StenosisAortic Valve Stenosis► In old adults, aortic valve with In old adults, aortic valve with

sclerotic or stenotic change resclerotic or stenotic change resulted from sulted from fibrocalcific chanfibrocalcific change ge :: R’t 2R’t 2ndnd ICS: impure, noisy, harsh ICS: impure, noisy, harsh

(jet turbulence)(jet turbulence) LV impulse: pure, musical (froLV impulse: pure, musical (fro

m periodic high-frequency vibram periodic high-frequency vibrations of the fibrocalcific aortic ctions of the fibrocalcific aortic cusps)usps)

( ( Gallavardin dissociationGallavardin dissociation --- --- Noisy right basal and musical Noisy right basal and musical apical apical ))

Aortic Valve StenosisAortic Valve Stenosis

D/D from high-pitch apical murmur of MRD/D from high-pitch apical murmur of MR►VPC followed by pauses longer than the dominaVPC followed by pauses longer than the domina

nt cycle lengthnt cycle length

Intensity of AS: increaseIntensity of AS: increase

Intensity of MR: unchangeIntensity of MR: unchange

Pulmonary Valve StenosisPulmonary Valve Stenosis

► Location: Right side of the heartLocation: Right side of the heart► Length and configuration: signs of severityLength and configuration: signs of severity

Still MurmurStill Murmur

►Normal vibratory midsystolic murmurNormal vibratory midsystolic murmur►Short, buzzing, pure and medium in frequeShort, buzzing, pure and medium in freque

ncyncy►Generated by low-frequency periodic vibratGenerated by low-frequency periodic vibrat

ions of normal pulmonary leaflets or a left ions of normal pulmonary leaflets or a left LV false tendonLV false tendon

►Typically heard between LLSB and apexTypically heard between LLSB and apex

Innocent Midsystolic MurmurInnocent Midsystolic Murmur

► Location: second left intercostal spaceLocation: second left intercostal space► Aortic sclerotic murmur (most common)Aortic sclerotic murmur (most common)► Exaggeration of normal ejection vibrations within Exaggeration of normal ejection vibrations within

the pulmonary trunkthe pulmonary trunk: : relatively impure, best heard in the left relatively impure, best heard in the left

22ndnd ICS ICS..► In patients with diminished anteroposterior chest dIn patients with diminished anteroposterior chest d

imensionimension

Midsystolic Murmur from MRMidsystolic Murmur from MR

►Usually in ischemic heart disease associated witUsually in ischemic heart disease associated with LV regional wall motion abnormalities.h LV regional wall motion abnormalities.

►Impaired integrity of the muscular component of Impaired integrity of the muscular component of the mitral apparatusthe mitral apparatus Early systolic competence of the mitral valveEarly systolic competence of the mitral valve Midsystolic incompetenceMidsystolic incompetence Late systolic decline in regurgitant flowLate systolic decline in regurgitant flow

Holosystolic MurmursHolosystolic Murmurs

► Left heart: Left heart: MRMR► Right heart: Right heart: TRTR► Between the ventricles: Between the ventricles:

a restrictive a restrictive VSDVSD► Between the great arteries:Between the great arteries:

Aortopulmonary connectionAortopulmonary connection(pulmonary vascular resistance rise t(pulmonary vascular resistance rise to abolish the diastolic portion of the o abolish the diastolic portion of the continuous murmur)continuous murmur)

A A persistentpersistent high pressure / resistance systolic flow to high pressure / resistance systolic flow to a low pressure / resistance vascular beda low pressure / resistance vascular bed


Direction of radiation of MRDirection of radiation of MR► Jet Jet forward and medialforward and medial against the atrial septum n against the atrial septum n

ear the origin of the aorta: murmur radiation to the ear the origin of the aorta: murmur radiation to the left sternal edgeleft sternal edge, , basebase and and neckneck

► JetJet posterolateralposterolateral with the LA: murmur radiation t with the LA: murmur radiation to the o the axillaaxilla, , left scapula angleleft scapula angle and the and the vertebral colvertebral columnumn with with bone conductionbone conduction from the C spine to L s from the C spine to L spinepine


Diagnostic feature of TRDiagnostic feature of TR►Carvallo signCarvallo sign --- --- inspiratory increaseinspiratory increase in loin lo

udness udness

Due to increase RV volume during inspiraDue to increase RV volume during inspiration tion

Stroke volume Stroke volume ↑↑

Regurgitant flow velocity ↑Regurgitant flow velocity ↑

Early Systolic MurmursEarly Systolic Murmurs

►Begins with S1, diminish in decrescendo anBegins with S1, diminish in decrescendo and end well before S2, generally at or before d end well before S2, generally at or before midsystolemidsystole

►Certain types of acute severe MR, TR and Certain types of acute severe MR, TR and VSDVSD

Early Systolic MurmursEarly Systolic Murmurs

►A feature of TR with A feature of TR with normal RV systolic prenormal RV systolic pressuressure, , ex. TR caused by IEex. TR caused by IE

►VSDVSD A A small VSDsmall VSD (constrictive): a soft, pure, high-fr (constrictive): a soft, pure, high-fr

equency, early systolic murmur localized to the equency, early systolic murmur localized to the mid- or lower left sternal edgemid- or lower left sternal edge

A A non-constrictive VSD with non-constrictive VSD with elevated pulm. vaelevated pulm. vascular resistancescular resistance

Late Systolic MurmursLate Systolic Murmurs

► Begin in mid- to late systole and proceed up to S2Begin in mid- to late systole and proceed up to S2► Prototype: Prototype: Mitral valve prolapseMitral valve prolapse► Response to postural maneuvers / amyl nitriteResponse to postural maneuvers / amyl nitrite

Prompt standing after squatting / valsalva maneuver: loPrompt standing after squatting / valsalva maneuver: longer and softernger and softer

Squatting / handgrip (LV volumeSquatting / handgrip (LV volume↑)↑): shorter and louder: shorter and louder

► An intermittent, striking systolic whoop or honk -- An intermittent, striking systolic whoop or honk -- spontaneously or in response to maneuvers: from spontaneously or in response to maneuvers: from mitral leaflets and chordae tendineaemitral leaflets and chordae tendineae

Heart MurmurHeart MurmurDiastolic murmurDiastolic murmur

► Early diastolic murmur Early diastolic murmur AR, PR AR, PR

► Mid-diastolic murmur Mid-diastolic murmur MS, TS and atrial tumors,MS, TS and atrial tumors, increase flow through no increase flow through non-obstructive AV valven-obstructive AV valve

► Late diastolic murmur Late diastolic murmur Austin-Flint murmurAustin-Flint murmur

Early Diastolic Murmurs ---Early Diastolic Murmurs --- AR AR

► Left sideLeft side of the heart, esp. with the diaphragm of th of the heart, esp. with the diaphragm of the stethoscopee stethoscope From primary valvular disease: best heard along the left From primary valvular disease: best heard along the left

sternal border in the 3rd and 4th intercostal spacesternal border in the 3rd and 4th intercostal space From From ascendingascending aorta dilatationaorta dilatation: along the: along the rightright sternal sternal

borderborder

► Esp. leaning forward and during a held, deep exhalEsp. leaning forward and during a held, deep exhalationation

► Beginning immediately after A2, high frequencyBeginning immediately after A2, high frequency

Early Diastolic Murmurs ---Early Diastolic Murmurs --- AR AR

►Chronic ARChronic AR Moderate: murmur throughout diastoleModerate: murmur throughout diastole Severe: more obvious decrescendoSevere: more obvious decrescendo

►Radiation to the right sternal edge: aortic roRadiation to the right sternal edge: aortic root dilatation, as in Marfan syndromeot dilatation, as in Marfan syndrome

Early Diastolic MurmursEarly Diastolic Murmurs --- --- Acute ARAcute AR

D/D from chronic AR

Often loud, Grade 4Quite soft, Grade 2

Early Diastolic MurmursEarly Diastolic Murmurs

Graham Steell murmur (of pulmonary hypertenGraham Steell murmur (of pulmonary hypertensive pulmonary regurgitation)sive pulmonary regurgitation)

► Begin with loud P2Begin with loud P2► High pulmonary pressure on the incomplete P valveHigh pulmonary pressure on the incomplete P valve

High diastolic pressure gradient between the pulmHigh diastolic pressure gradient between the pulmonary artery and the RVonary artery and the RV

High-velocity regurgitant flowHigh-velocity regurgitant flow

High-frequency blowing murmur, throughout diastHigh-frequency blowing murmur, throughout diastoleole

Amplitude of the murmur: uniform throughout moAmplitude of the murmur: uniform throughout most of diastolest of diastole

Mid-Diastolic MurmursMid-Diastolic Murmurs

Mitral stenosisMitral stenosis►Following the mitral opening snap, originatiFollowing the mitral opening snap, originati

ng within the LV, transmission to the chest ng within the LV, transmission to the chest wall, maximal over the LV impulsewall, maximal over the LV impulse

►Left lateral decubitus positionLeft lateral decubitus position►Vigorous voluntary cough or a few sit-upsVigorous voluntary cough or a few sit-ups HR and mitral valve flow HR and mitral valve flow ↑↑ Murmur reinforcedMurmur reinforced

Mitral stenosisMitral stenosis

►In Af, duration of the murmur is a sign of thIn Af, duration of the murmur is a sign of the degree of obstruction at the mitral orificee degree of obstruction at the mitral orifice

►In sinus rhythmIn sinus rhythm


Tricuspid stenosisTricuspid stenosis►D/D from MS: D/D from MS:

Loudness of tricuspid murmur Loudness of tricuspid murmur ↑with inspirat↑with inspirationion

Tricuspid murmur confined to a localized arTricuspid murmur confined to a localized area along the ea along the left lower sternal edgeleft lower sternal edge

Late Diastolic MurmursLate Diastolic Murmurs

►Occur immediately before S1Occur immediately before S1

►Usually originate at the mitral or tricuspid oUsually originate at the mitral or tricuspid orifice because of obstruction (MS, TS)rifice because of obstruction (MS, TS)

►Tricuspid stenosis: crescendo-decrescendo. Tricuspid stenosis: crescendo-decrescendo. Fading before S1Fading before S1

►Austin-Flint murmur in ARAustin-Flint murmur in AR

Continuous MurmursContinuous Murmurs

► PDA (loudest in PDA (loudest in left left 22ndnd ICS) ICS)► Coronary AV fistula (loudest in lower sternal border) Coronary AV fistula (loudest in lower sternal border) ► Ruptured sinus of Valsalva aneurysm (loudest in Ruptured sinus of Valsalva aneurysm (loudest in rightright u u

pper sternal border)pper sternal border)

Continuous MurmursContinuous Murmurs

► Arteriovenous continuous murmursArteriovenous continuous murmurs► Arterial continuous murmursArterial continuous murmurs► Continuous venous murmurContinuous venous murmur

Innocent cervical venous hum: the most common tInnocent cervical venous hum: the most common type of normal continuous murmur, in healthy childype of normal continuous murmur, in healthy children and healthy young adults, esp. pregnancyren and healthy young adults, esp. pregnancy

Thyrotoxicosis and anemiaThyrotoxicosis and anemia

Heart Murmur ApproachHeart Murmur Approach

Approach to the Patient with a Approach to the Patient with a Heart MurmurHeart Murmur

► Cardiac echo is indicated as follows:Cardiac echo is indicated as follows:

1.1. Loud murmur (>= grade 3)Loud murmur (>= grade 3)

2.2. Holosystolic or late systolic murmurHolosystolic or late systolic murmur

3.3. Systolic murmur becomes louder or longer during Systolic murmur becomes louder or longer during Valsava maneuver (susp. HOCM or MVP)Valsava maneuver (susp. HOCM or MVP)

4.4. Systolic murmur with clinical findings suggesting Systolic murmur with clinical findings suggesting IE, thromboembolism or syncopeIE, thromboembolism or syncope

5.5. Systolic murmur associated with abnormal EKGSystolic murmur associated with abnormal EKG

Heart MurmurHeart Murmur

►Pericardial RubsPericardial Rubs

Triple phasesTriple phases midsystolic, middiastolic an midsystolic, middiastolic and late diastolicd late diastolic

►Detected in Acute pericarditisDetected in Acute pericarditis

Dynamic AuscultationDynamic AuscultationRespirationRespiration

► Diastolic sounds and ejection soundsDiastolic sounds and ejection sounds S3, S4, opening snapS3, S4, opening snap

►From right heart: augmented during inspirationFrom right heart: augmented during inspiration►From left heart: diminished during inspirationFrom left heart: diminished during inspiration

Ejection sounds intensityEjection sounds intensity►Right heart, ex. PS: Right heart, ex. PS: ↓↓ during inspiration during inspiration►Left heart: not effected, except tetralogy of FallotLeft heart: not effected, except tetralogy of Fallot

► Murmur: more pronounced on the right side murmurMurmur: more pronounced on the right side murmur ( ( Venous return increase during inspiration Venous return increase during inspiration ))

↑↑during inspiration: TS, PR (diastolic murmur), TR during inspiration: TS, PR (diastolic murmur), TR and Ebstein anomaly (presystolic murmur), MVPand Ebstein anomaly (presystolic murmur), MVP

Dynamic AuscultationDynamic AuscultationValsalva ManeuverValsalva Maneuver

Dynamic AuscultationDynamic Auscultation►Valsalva maneuverValsalva maneuver reduced LV filling reduced LV filling►Standing—reduce venous returnStanding—reduce venous return►Squatting—increase venous return and systSquatting—increase venous return and syst

emic resistenceemic resistence►Lying—increase venous returnLying—increase venous return►Hand grip—increase cardiac output and BPHand grip—increase cardiac output and BP►Amyl nitriteAmyl nitritevasodilationvasodilationBP dropBP drop refl refl

ex tachycardiaex tachycardiaincrease cardiac outputincrease cardiac output►PhenylephrinePhenylephrine opposite effect of amyl nit opposite effect of amyl nit

iteite

Dynamic AuscultationDynamic Auscultation

Thanks for Your Thanks for Your AttentionAttention

Systolic Arterial MurmursSystolic Arterial Murmurs

► Normal anatomical arteries with normal or increaseNormal anatomical arteries with normal or increased flowd flow

► Abnormal arteries with tortuosity or luminal narroAbnormal arteries with tortuosity or luminal narrowingwing

► Systolic and crescendo-decrescendo configurationSystolic and crescendo-decrescendo configuration► In old adults: atherosclerotic narrowing of a carotid,In old adults: atherosclerotic narrowing of a carotid,

subclavian or iliofemeral artery subclavian or iliofemeral artery► A rare pulmonary arterial systolic murmur: by lumiA rare pulmonary arterial systolic murmur: by lumi

nal narrowing after a pulmonary embolusnal narrowing after a pulmonary embolus

Supraclavicular Systolic MurmurSupraclavicular Systolic Murmurss

►Often heard in children and aldolescentsOften heard in children and aldolescents►Originate at the aortic origins of normal major Originate at the aortic origins of normal major

branchiocephalic arteriesbranchiocephalic arteries►Crescendo-decrescendo, abrupt onset, loud anCrescendo-decrescendo, abrupt onset, loud an

d radiation below the claviclesd radiation below the clavicles►Murmur decrease in response to hyperextensiMurmur decrease in response to hyperextensi

on of the shoulderson of the shoulders

Systolic Mammary SouffleSystolic Mammary Souffle

►Over the breast because of increase flow Over the breast because of increase flow through normal arteries during late pregnancy through normal arteries during late pregnancy or in lactatingor in lactating

►Begin after S1Begin after S1


►Appreciable aortic valve incompetence or Appreciable aortic valve incompetence or large left-to-right shunts, preceded by S3large left-to-right shunts, preceded by S3

►Short, mid-diastolic aortic valve flow Short, mid-diastolic aortic valve flow murmur in complete AV blockmurmur in complete AV block

►Pulmonary valve regurgitationPulmonary valve regurgitation

Dynamic AuscultationDynamic AuscultationMuller ManeuverMuller Maneuver

►Close the nose and seal the mouthClose the nose and seal the mouth

then forcibly inspire for 10 secondsthen forcibly inspire for 10 seconds

Widen the split S2 and augment murmurs Widen the split S2 and augment murmurs originating in the right heartoriginating in the right heart

Heart MurmurHeart Murmur

Dynamic AusculationLesionLesion MurmurMurmur ValsalvaValsalva Hand Hand

GripGripSquaSquatt

StanStandd

ASAS mid-mid-systolicsystolic

↓ ↓ ↓ ↓ ↑ ↑ ↓ ↓

MRMR holosystoliholosystolicc

↓ ↓ ↑ ↑ ↑ ↑ ↓ ↓

VSDVSD holosystoliholosystolicc

↓ ↓ ↑ ↑ ↑ ↑ ↓ ↓

MVPMVP Late Late systolicsystolic

↑ ↑ ↓ ↓ ↓ ↓ ↑ ↑

HOCMHOCM holosystoliholosystolicc

↑ ↑ ↓ ↓ ↓ ↓ ↑ ↑

Amyl Amyl nitritnitritee

↑ ↑

↓ ↓

↓ ↓

↑ ↑

↑ ↑

Heart MurmurHeart MurmurSystolic murmurSystolic murmur

►Early Systolic MurmurEarly Systolic Murmuracute MR(giant V)acute MR(giant V) TR with normal RV systolic pressureTR with normal RV systolic pressure►Midsystolic murmur(ejection murmur) Midsystolic murmur(ejection murmur) AS, PS,AS, PS,

VSD,ASDVSD,ASD►Late systolic murmurLate systolic murmurMVPMVP►Holosystolic murmur(regurgitant murmur) Holosystolic murmur(regurgitant murmur) MM

R,TR(Carvallo signR,TR(Carvallo sign selective inspiratory incre selective inspiratory increase murmur),VSDase murmur),VSD

Documents

Heart Disease Braunwald Chapter 4 Physical Examination (II) --- Heart Murmur --- Heart Murmur Presenter: R4 劉嚴文