Lecture Notes: Heart Murmurs

Introduction

• Focus on key points for exams.
• Includes mnemonics, tips, and tricks.

Systolic vs Diastolic Murmurs

Systolic Murmurs

• Occur between S1 and S2.
• Types:
  • Aortic stenosis
  • Pulmonic stenosis
  • Mitral regurgitation
  • Tricuspid regurgitation
  • Mitral valve prolapse

Diastolic Murmurs

• Occur after S2, before S1.
• Types:
  • Mitral stenosis
  • Pulmonary regurgitation
  • Aortic regurgitation
  • Tricuspid stenosis
• Mnemonic: "Ms. Prartz died" (Mitral Stenosis, Pulmonary Regurgitation, Aortic Regurgitation, Tricuspid Stenosis = Diastolic)

Venous Return Effects

• Increase venous return (squatting, leg raise): Increases most murmurs.
• Decrease venous return (standing, Valsalva): Decreases most murmurs.
• Exceptions:
  • Mitral valve prolapse (MVP)
  • Hypertrophic cardiomyopathy
• Mnemonic: "MVP hates conforming to the rules"

Left vs Right-Sided Murmurs

• Right-sided murmurs increase with inspiration (Mnemonic: Rinspiration).
• Left-sided murmurs decrease with inspiration.
• Locations help differentiate:
  • Aortic stenosis: Right upper sternal border
  • Pulmonic stenosis: Left upper sternal border

Auscultation Mnemonic

• "All Patients Eagerly Take Medicine"
  • Aortic: Right upper sternal border
  • Pulmonic: Left upper sternal border
  • Erb's Point: 3rd intercostal space
  • Tricuspid: 4th/5th intercostal space
  • Mitral: 5th intercostal, midclavicular line

Specific Murmurs

Aortic Stenosis

• Most common valvular disease.
• Etiology: Young (<70): Congenital (bicuspid valve); Old (>70): Calcifications.
• Symptoms: End-stage: Angina, Syncope, Heart Failure (ASH)
• Murmur: Systolic, crescendo-decrescendo, radiates to carotids.
• Treatment: Valve replacement.

Aortic Regurgitation

• Etiology: Chronic: Rheumatic Heart Disease; Acute: Endocarditis, Aortic dissection.
• Symptoms: Often asymptomatic, can cause heart failure.
• Murmur: Diastolic decrescendo, left upper sternal border.
• Physical Exam: Bounding pulses, Quinkey's pulses, Corrigan pulse.
• Treatment: Surgical, afterload reducers.

Mitral Regurgitation

• Etiology: MVP (most common in U.S.), Rheumatic Heart Disease.
• Symptoms: Dyspnea, possible AFib.
• Murmur: Holosystolic, radiates to axilla.
• Treatment: Valve repair/replacement, afterload reducers.

Mitral Stenosis

• Etiology: Rheumatic Heart Disease (most common).
• Symptoms: AFib, Ortner syndrome (hoarseness), Mitral facies.
• Murmur: Diastolic rumbling, opening snap (MSOS: Microsoft OS).
• Treatment: Balloon valvuloplasty, surgery if needed.

Mitral Valve Prolapse

• Etiology: Primary (degenerative), Secondary (Marfan syndrome).
• Symptoms: Often asymptomatic, but may have MVP syndrome (anxiety, palpitations).
• Murmur: Mid-late systolic click.
• Treatment: Reassurance, beta blockers for symptoms.

Pulmonic and Tricuspid Murmurs (Right-sided)

• Pulmonic Stenosis: Systolic crescendo-decrescendo, left upper sternal border.
• Pulmonic Regurgitation: Diastolic decrescendo, left upper sternal border.
  • Known as Graham Steel murmur.
• Tricuspid Stenosis: Diastolic, left lower sternal border, opening snap.
• Tricuspid Regurgitation: Holosystolic, tricuspid area, common in adults.

Review Questions

1. Diastolic Murmurs: Ms. Prartz died (Mitral Stenosis, Pulmonary Regurg, Aortic Regurg, Tricuspid Stenosis).
2. Aortic Stenosis Murmur: Systolic crescendo-decrescendo, radiates to carotids.
3. Mitral Regurgitation Cause (U.S.): MVP
4. Quinkey's Pulse: Capillary pulsation in nail beds (Aortic Regurg).
5. Mitral Stenosis Cause: Rheumatic Heart Disease.

Conclusion

• Additional resources: Podcast - Cram the Pants.
• Good luck on exams and studies in PA school.