Lecture: Heart Murmur Auscultation and Identification

Key Auscultation Areas

• Mnemonic: APTM (Apartment M)
  • Aortic Area: Right second intercostal space
  • Pulmonic Area: Left second intercostal space
  • Tricuspid Area: Left fourth intercostal space
  • Mitral Area (Apex):

Identifying Murmurs

• Key Points:
  • Determine if murmur is systolic or diastolic.
  • Determine location of murmur.
  • Use the mnemonic APTM to identify the relevant heart valve.

Example Case

• 78-year-old male: Complains of dyspnea and exertional angina.
  • Systolic murmur in the apical area = Mitral regurgitation.

Murmur Characteristics

• Mitral Stenosis vs. Mitral Regurgitation:
  • Systolic Murmur: Mitral regurgitation
  • Diastolic Murmur: Mitral stenosis

Maneuver Effects on Murmurs

• Inspiration and Expiration Rules:

  • Inspiration: Right-sided murmurs get louder.
  • Expiration: Left-sided murmurs get louder.

• Preload vs. Afterload:

  • Increasing Preload: Murmurs generally louder (exceptions: HOCM and MVP)
  • Decreasing Preload: Murmurs generally softer
  • Increasing Afterload: Louder regurgitant murmurs, softer HOCM and MVP
  • Decreasing Afterload: Louder HOCM and MVP

Techniques to Adjust Preload/Afterload

• Increase Preload: Squatting, leg raising
• Decrease Preload: Valsalva maneuver
• Increase Afterload: Hand grip
• Decrease Afterload: Amyl nitrite

High-Yield Murmur Characteristics

• Aortic Stenosis:
  • Crescendo-decrescendo murmur
  • Radiates to the carotid
  • SAD Mnemonic: Syncope, Angina, Dyspnea
• Mitral Regurgitation:
  • Holosystolic murmur
  • Radiates to the axilla
  • History of rheumatic fever: "Rue Mitral"
• Tricuspid Regurgitation:
  • Holosystolic murmur
  • Associated with IV drug use: "Try some drugs"
• Mitral Stenosis:
  • Opening snap
  • History of rheumatic fever
  • Mnemonic: "Operating System is Microsoft" (OS = MS)
• HOCM (Hypertrophic Obstructive Cardiomyopathy):
  • Louder with decreased preload/afterload
  • Associated with family history of sudden cardiac death
• Mitral Valve Prolapse (MVP):
  • Mid-systolic click
  • Associated with young women and psychiatric history
  • Mnemonic: "To win MVP, your team has to click"

Additional Notes

• Certain murmurs (PDA, VSD, ASD) not covered in detail; research separately.

This comprehensive guide to heart murmurs highlights key points necessary for exams and clinical understanding, focusing on maneuvers and mnemonic aids for quick recall.