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IM CV murmurs USMLE 2


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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?

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
MI w/ papillary muscle rupture;

Etiology of Chronic Mitral Regurgitation
Rheumatic fever;

Mitral Prolapse;

LV dilation
Diagnostic tests for Mitral Regurgitation

- Auscultation


- Echo
Auscultation: Loud, holosystolic apical murmur radiating to axilla

EKG: large LA

Echo: valve problem
Tx for Mitral Regurgitation (6)*
Endocarditis prophylaxis;
Surgery if severe;
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
WAH-HA-H-ide pulse pressure:

Wet beri-beri;
Aortic Regurgitation;
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
- Syncope;
- Angina;
- Dyspnea on Exertion

- Forceful apex beat
- narrow Pulse Pressure
- Paradoxical S2 split
- heard in carotids
Diagnostic test results for Aortic Stenosis

- Auscultation


- Echo

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?
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

Idiopathic (but inc w/ HTN);

Collagen vascular dz
(2) causes of Valvular dz thereby causing Aortic Regurg
Rheumatic heart dz;

(6)* causes of proximal Aortic root dissection thereby causing Aortic Regurg
Third Trimester Pregnancy;
Marphans (Cystic medial necrosis);
Turner's syndrome;

(Aortic arch is shaped like a mountain)
Names of the unique signs of Aortic regurg
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?
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
Tx LV heart failure;

Endocarditis prophylaxis;

Valve replacement
Etiology of Tricuspid stenosis (3)*



Rheumatic heart dz
Murmur presentation:
peripheral edema, JVD, hepatomegaly, ascites, jaundice
Tricuspid stenosis


Tricuspid Regurg
Auscultation results for Tricuspid stenosis?

Diastolic, rumbling low-pitched heard w/ Inspiration

Tx: Repair valve

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);


Right papillary muscle rupture w/ MI;

Tricuspid valve lesions
(rheumatic heart or bacterial endocarditis)
Holosystolic murmurs

Mitral Regurg;

Tricuspid regurg;

Ventricular Septal Defect
Number 1 cause of death in CHF patients
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
Tricuspid Dying Slowly:

Tx heart failure;


Surgical repair of valve
What is done first if a patient has hyperK and peaked T-waves? Why?
give Calcium to stabilize cardiac membrane
Diastolic apical rumble and opening snap
Mitral stenosis
Late systolic murmur w/ midsystolic click

What is confirming test?
Mitral Prolapse

Valsalva - click starts earlier, murmur prolonged
High-pitched apical blowing holosystolic murmur

where does it radiate?
Mitral Regurg

radiates: Axilla
Diastolic rumble louder w/ inspiration
Tricuspid stenosis
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
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
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?

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)*

Aortic Regurg
Atrial-Septal defect (fixed split S2)

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