What is the primary cause of mrumurs in the heart or great vessels?

Turbulence (obstruction of flow, high pressure-->low pressure, protusion into stream of flow)

What are the 7 ways that cardiac murmurs are characterized?

-where they occur in cardiac cycle

- location on chest wall

- quality of sound

- shape

- duration

- direction of radiation or transmission

- intensity

What Levine murmur grade describes the intensity of the murmur as faint, but loud enough to be heart immediately upon placing the stethoscope onto the chest?

Grade 2/6

What Levine murmur grade describes the intensity of the murmur as an intermediate in intensity, prominent, but not loud?

Grade 3/6

What Levine murmur grade describes the intensity of the murmur as faint and inaudible when the stethoscope is first placed on the chest, in a way the examiner must "tune in" to hear the murmur?

Grade 1/6

What Levine murmur grade describes the intensity of the murmur as loud and usually associated with a palpable vibration (thrill)?

Grade 4/6

What Levine murmur grade describes the intensity of the murmur as so loud it can be heart with the side of the stethoscope on the chest?

Grade 5/6

What is the most common type of cardiac murmur? How is it produced and when does it occur?

- Midsystolic Murmurs

- produced by forward flow across the aortic and pulmonic valves

- between S1 and S2

What is the contour and quality of the sound of a midsystolic murmur?

-diamond-shaped (crescendo-decrescendo) and harsh or saw-like

Why do midsystolic murmurs exhibit postextrasystolic potentiation (an increase in intensity during the beat that follows a long pause in the cardiac rhythm)?

- midsystolic murmurs caused by flow

- because the beat following the pause is more forceful (increased contractility-->Ca2+) than normal beats

- because the pause increases ventricular filling and stroke volume

What are some association conditions with a functional (non-obstructive) midsystolic murmur?

- pregnancy, hyperthyroidism, anemia, and fever (increased rate or volume of blood flow across a normal valve)

What are the two pathological causes of an early-to-mid peaking midsystolic murmur?

- dilated aorta (aneurysm)

- thickened valve cusp and calcifications ling the wall of the aorta (aortic sclerosis) --> common in elderly

What types of midsystolic murmurs peak during mid-late systole?

- valvular stenosis or subvalvular stenosis

Describe the aortic valve stenosis murmur in these terms:

-when it occurs in cardiac cycle

- location on chest wall

- quality of sound

- shape

- duration

- direction of radiation or transmission

- intensity

When

- midsystolic, peaking in mid-late systole

Where

- @ 2nd RICS and apex

Quality

- whooshing

Shape

- crescendo-decrescendo

Duration

- S1-->S2

Radiation

- right clavicle or into the carotid arteries

Intensity

- high-grade (3/6 to 4/6)

A narrow pulse pressure and slow, delayed carotid upstroke can occur from what heart condition?

Severe aortic stenosis

What other heart sound is an aortic valve stenosis murmur most commonly associated with?

ejection sound

What can aortic valve stenosis do to the apical impulse when an aortic outflow murmur is present?

make it sustained

Although it does not help differentiate severe from mild aortic stenosis, what can happen to S2?

- may be narrowly split, single, or paradoxically split (variation)

What happens to the intensity of an aortic stenosis murmur during normal inspiration and during the strain of sustained Valsalva?

Decreases

If a radial pulse is slightly delayed compared to the brachial pulse, what condition is probably present?

Severe aortic stenosis

Where is an IHSS/HOCM murmur most prominent?

mid-to-lower LSB and @ apex/2nd RICS

During a sustained valsalva or standing what happens to the intensity of an IHSS murmur?

increases (due to smaller LV cavity)

What maneuvers can decrease the intensity of IHSS murmurs and make the LV cavity larger?

passive leg elevation or squatting

Where and at what intensity is the pulmonary stenosis murmur heard?

@ 2nd/3rd LICS

&

less intense than the aortic stenosis murmur

What is the contour, timing, and radiation quality of the pulmonic stenosis murmur?

crescendo-decrescendo, mid-to-late systole peak, NO radiation into carotid arteries

What associated JVP and LSB Impulse findings occur with pulmonic stenosis?

Giant 'a' waves and sustained impulse

With prolonged RV ejection, pulmonic stenosis does what to S2?

Wide physiologic splitting

What are the characteristics of pulmonic stenosis ejection sound?

- localized to the upper left sternal border

- decreases (sometimes inaudibly) during inspiration

Like most other murmurs, what happens to the pulmonic stenosis murmur during inspiration/leg elevation?

its intensity increases

What is the cause of holosystolic murmurs and what can be said about their contour from S1 to S2?

- caused by retrograde flow (regurgitation) from high-pressure to low-pressure chambers

- blowing quality and a constant frequency from S1 to S2

What is important to note about regurgitation murmurs regarding the fact that there are two outlets to normal flow?

they do not show postextrasystolic potentiation (no change in murmur grade)

What are the three conditions that create a holosystolic murmur?

Chronic tricuspid regurgitation

Chronic mitral regurgitation

Ventricular Septal Defect (VSD)

Where is a mitral regurgitation murmur primarily heard and where does it radiate to?

@ apex --> left axilla

- can radiate to top of head or thoracic spine when the cause is a ruptured anterior chordae

What can increase or decrease a chronic mitral regurgitation murmur's intensity?

Increase --> handgrip exercise or transient arterial occlusion (increase in peripheral resistance)

Decrease --> valsalva and inspiration (also amyl nitrate)

What are three common associated findings with chronic mitral regurgitation?

- wide physiologic splitting of S2 (LV ejection shortened)

- hyperdynamic apical impulse (ventricular dilation)

- S3 @ the apex --> severe regurgitation

Following the saying 'you diagnose mitral regurgitation in systole, but assess its severity in diastole', what are you looking for in diastole?

- S3 shows up with severe regurgitation

- rumbling diastolic flow murmur also can be present

Where can you hear a chronic tricuspid regurgitation murmur, where does it radiate, and what causes it to be louder?

4th/5th LICS along LSB

radiates toward xiphoid

louder udring inspiration (Carvallo's sign) and with sustained abdominal pressure

What JVP and observatory findings occur with chronic tricuspid regurgitation?

- giant v waves (backflow during ventricular contraction)

- ear lobes and liver may pulsate with heartbeat

What and where do you hear a VSD murmur?

High-grade holosystolic murmur @ the 4th-6th LICS (septum)

Why would a VSD probably produces the greatest splitting of S2?

It shortens LV ejection AND prolongs RV ejection

What can we say about the apical impulse and the intensity of a VSD murmur with increased peripheral resistance?

hyperdynamic, displace down and to the left (ventricular dilation)

increased intensity due to one outlet (aorta) having a greater resistance to flow

What is primarily the only early-systolic murmur, what is its contour like, and what is it caused by?

Acute mitral regurgitation

- begins with S1, increases toward mid-systole, fades out in late systole (before S2)--> (LA pressure rises rapidly and limits duration of regurgitation)

- caused by chordal rupture or papillary muscle infarction

What causes late systolic murmurs and what is their timing related to S1 and S2?

- produced by mild regurgitant flow from mitral/tricuspid valve prolapse

- begin in midsystole and crescendo into S2 (preceded by midsystolic click)

What are two things that make late systolic murmurs longer and louder?

decreased ventricular volume (valsalva or standing)

increase in myocardial contractility

Why do late systolic murmurs become longer and softer with decreased resistance to ventricular ejection (afterload)?

decreased afterload makes the ventricle smaller and causes the AV valve to prolapse earlier

AND

decreased afterload improves ventricular ejection which decreases the volume of retrograde flow across AV valve

What are the two types of diastolic murmurs and what causes them?

Mid-diastolic filling murmurs (rumbles) - forward flow across AV valves (low-pitched)

Early-diastolic regurgitant murmurs - retrograde flow across semilunar valves (high-pitched)

What kind of murmur does mitral stenosis produce?

low-pitched, rumbling, mid-diastolic filling murmur

Where is mitral stenosis murmur exclusively located?

localized to the cardiac apex (may only be heard in the left lateral decubitis postion)

What is the timing and contour of a mitral stenosis murmur?

Begins with an opening snap (after S2) and decreases in intensity until just before S1, where it then increases again (except in A-Fib)

What is the crescendo effect that occurs at the end of a mitral stenosis murmur called and what causes it?

Presystolic accentuation

- occurs because LV pressure is beginning to rise and compounds with the stenotic mitral valve to increase the intensity of the murmur

What can be done to increase the grade of a mitral stenosis murmur?

elevating the legs above heart level (increased venous return) gets the intensity no greater than grade 1 or 2

What are other findings that can occur with a mitral stenosis murmur?

Increased S1 intensity

Sustained L parasternal impulse due to RV hypertrophy

Normal/Small apical impulse (medial to L midclavicular)

Where can you find a tricuspid stenosis murmur?

What can you do to increase its intensity?

What JVP findings area associated with it?

Lower LSB

inspiration and leg elevation (venous return)

giant 'a' waves and slow 'y' descent

What is the most common early-diastolic regurgitant murmur?

Chronic aortic regurgitation

What Pt position is unique when listening for a chronic aortic regurgitation murmur?

Usually while sitting, Pt leans forward and holds breath after forced exhalation

Where is a chronic aortic insufficiency (AI) murmur heard and what its contour, quality, and intensity?

@ 2nd RICS, 3rd LICS, apex

(aortic band)

begins with A2 and decrescendos until late diastole

high-pitched, blowing quality

increases in intensity with increased vascular resistance

(handgrip, squatting or isometric exercise)

What are some associated findings that could (but don't have to) indicate chronic AI?

Wide Pulse Pressure

(large stroke volume increases systolic bp, regurg decreases diastolic bp)

Water-hammer Pulse

Pulsus Bisfiriens

(transient obstruction due to large stroke volume pulling walls of aorta together)

Quincke's pulse

('to-and-fro' pulsation of blood in proximal fingernail bed)

DeMusset's sign

(bobbing of head with heart beat)

lighthouse sign
(alternate flushing and blanching of face)

Muller's sign

(pulsation of Uvula)

Becker's sign

(Pulsation of retinal arterioles)

Durziez's sign

('to-and-fro' bruit audible over femoral arter when pressure is applied just proximal to the stethoscope)

Ewart's sign

(dullness to percussion, increased tactile fremitus and egophony at lower tip of left scapula)

Hill's sign

(sphygmomanometric foot-arm blood pressure difference [foot>arm by 60 Hg])

Hyperdynamic apical impulse

(displaced down and to the left)

S3

Aortic ejection (mid-systolic) murmur

Austin Flint murmur

(mid-to-late rumbling diastolic murmur)

Which of the following is positive when 'to-and-fro' pulsation of blood occurs in the proximal fingernail bed when pressure is applied distally?

A. Quincke's pulse

B. DeMusset's sign

C. lighthouse sign

D. Muller's sign

E. Becker's sign

F. Duroziez's sign

G. Ewart's sign

H. Hill's sign

A. Quincke's pulse

Which of the following is positive when a bobbing of the head occurs with each heart beat?

A. Quincke's pulse

B. DeMusset's sign

C. lighthouse sign

D. Muller's sign

E. Becker's sign

F. Duroziez's sign

G. Ewart's sign

H. Hill's sign

B. DeMusset's sign

Which of the following is positive when an alternating flushing and blanching of the face is present?

A. Quincke's pulse

B. DeMusset's sign

C. lighthouse sign

D. Muller's sign

E. Becker's sign

F. Duroziez's sign

G. Ewart's sign

H. Hill's sign

C. lighthouse sign

Which of the following is positive when a pulsation of the uvula is present?

A. Quincke's pulse

B. DeMusset's sign

C. lighthouse sign

D. Muller's sign

E. Becker's sign

F. Duroziez's sign

G. Ewart's sign

H. Hill's sign

D. Muller's sign

Which of the following is positive when a pulsation of the retinal arterioles is present?

A. Quincke's pulse

B. DeMusset's sign

C. lighthouse sign

D. Muller's sign

E. Becker's sign

F. Duroziez's sign

G. Ewart's sign

H. Hill's sign

E. Becker's sign

Which of the following is positive when there is a 'to-and-fro' bruit over the femoral artery when pressure is applied proximal to the stethoscope?

A. Quincke's pulse

B. DeMusset's sign

C. lighthouse sign

D. Muller's sign

E. Becker's sign

F. Duroziez's sign

G. Ewart's sign

H. Hill's sign

F. Duroziez's sign

Which of the following is positive when there is dullness to percussion, increased tactile fremitus and agophony at the lower tip of the scapula?

A. Quincke's pulse

B. DeMusset's sign

C. lighthouse sign

D. Muller's sign

E. Becker's sign

F. Duroziez's sign

G. Ewart's sign

H. Hill's sign

G. Ewart's sign

Which of the following is positive when there is a sphygomomanometric foot-arm blood pressure difference of >60 mm Hg?

A. Quincke's pulse

B. DeMusset's sign

C. lighthouse sign

D. Muller's sign

E. Becker's sign

F. Duroziez's sign

G. Ewart's sign

H. Hill's sign

H. Hill's sign

Why does an aortic ejection (mid-systolic) murmur occur with chronic AI?

increased volume of blood ejected across the aortic valve in the forward direction

How is an Austin Flint murmur created?

regurgitant flow impinges upon the anterior leaflet of the mitral valve and partially closes it ("functional" mitral stenosis)

How can we distinguish an Austin Flint murmur from a mitral stenosis murmur?

- Inhalation of amyl nitrate decreases the intensity of the Austin Flint but increases the intensity of the mitral stenosis

- Presence of S3 is found more often in conjunction with an Austin Flint than a mitral stenosis murmur

How can we distinguish a valvular pulmonary regurgitation murmur from a chronic AI murmur?

- a pulmonary insufficiency murmur increases in intensity with inspiration (increased venous return)

- pulmonary does not cause peripheral manifestations

What is the high-pressure pulmonary regurgitation murmur associated with pulmonary HTN called?

Graham Steele murmur

(begins immediately with a loud S2 and is higher in pitch than a low-presure pulmonic regurgitation murmur)

What congenital heart problem presents with the following?

- a mid-systolic murmur at the 2nd LICS due to increased pulmonic flow

- a rumbling mid-diastolic murmur at the lower LICS due to increased tricuspid flow

- wide physiologic splitting

Atrial Septal Defect

What heart sounds does a patent ductus arteriosus (communication between the pulmonary artery and the aorta) present with?

- "continuous" or machinery murmur that persists through the cardiac cycle which is loudest at the 2nd LICS

- (can radiate to the clavicle and is heard best in supine position)

- Can affect S2 (paradoxical split)

What causes the visceral and parietal layers to rub and create the pericardial friction rub heart sound?

Pericardial inflammation (viral infection/renal failure/MI)

What can be done to alleviate pericardial friction rub chest pain?

Pt leans forward

What heart sound is heard best with the diaphragm, sounds like leather rubbing together, and has the following 3 components?

- systolic (ventricular contraction)

- early diastolic (passive vent. filling)

- late diastolic (atrial contraction)

Pericardial friction rub (@ mid-LSB)

What grade, timing, contour, and age group do innocent murmurs occur in?

Grade = < 3/6

Timing = ONLY systolic

Contour = NOT holosystolic

Age = school age children

What causes the cervical venous hum innocent murmur (continuous sound heard best in the neck above the sternal end of the clavicle when the pt is upright)?

Turbulent flow in the IJV caused by compression of the jugular by the transverse process of the atlas (C1)

What can be done to amplify and muffle a cervical venous hum on exam?

having the pt turn their head 30-60 degrees away from the side being examined

OR

compressing the jugular veins

What is the most common innocent murmur in children and when does it usually disappear?

Still's murmurs usually disappear around puberty

What murmur is midsystolic, vibratory from periodic vibrations across the LV outflow tract and aortic valve, heart at the 3rd LICS and apex, and loudest in the recumbent position?

Still's murmur

What murmur can be heard above the clavicles, after S1, in a diamond shape, occupies less than half of systole, and be decreased or abolished by hyperextending the shoulders towards the back?

Supraclavicular arterial murmur (innocent)