Key Insights on Heart Murmurs

Okay, so today we're going to be going over heart murmurs. I'm going to focus on the things you really need to know for the exams and just really the key points for all of these like I normally try to do with most of my videos. And then I'll also throw in some mnemonics and tips and tricks that helped me learn these while I was in PA school. So really quickly again, like I do in every video, thank you so much for the comments, the new subscriptions, the likes. I really, really appreciate it. So thank you again for that. So all right, before we get started with murmurs and breaking down what you need to know for each individual one, I want to review a few areas that will help you not only get the question right of the exam but also to help you in real life so first thing that i want to review is um uh differentiating between systolic and diastolic murmurs and really easy way i found to memorize them for the exam okay so there's um systolic and diastolic so systolic murmurs are going to occur between s1 and s2 heart sounds and as we can see here we have our systolic murmurs s1 when the mitral and tricuspid close and then s2 here where the aortic and pulmonary valve close so this is systolic falling in between s1 and s2 and then we have the systolic murmurs which are aortic stenosis pulmonic stenosis mitral regurg tricuspid regurg and mvp or mitral valve prolapse then we have our diastolic murmurs it's going to occur after s2 between s2 and s1 so diastolic is going to occur right here right after the aortic and pulmonary valve close and before s1 here so this is where diastolic is going to fall that's where your murmurs will be heard Now, how do you remember them? Let's also go over what the diastolic murmurs are. So, it's mitral stenosis, pulmonary regurg, aortic regurg, and tricuspid stenosis. So, a really easy way I found to remember them, and this is what I came up with. So, how do you remember which is systolic and which is diastolic? Really, obviously, just for the exams, but what I remember is the sentence, Ms. Prartz died. Ms. Prartz died, and what does that stand for? So, Ms. Prartz died. Here she is over here. Unfortunately, she died. So, Ms. Prartz died, Ms. Miss. stands for mitral stenosis. PR in Prarts stands for pulmonary regurgitation. AR stands for aortic regurg, and TS stands for tricuspid stenosis, and then died stands for diastolic. So any one of these in Ms. Prarts died is going to be a diastolic murmur. If it's not in the sentence Ms. Prarts died, it's not diastolic, and therefore it's systolic. So if you can remember this, you can remember all the diastolic murmurs, and therefore you know all the systolic murmurs too, because if it's not here, it's a systolic murmur. So just a really easy way to remember which is systolic and which is diastolic. So that's an easy way for you to remember that. Okay, so the second tip is related to venous return and its effect on the intensity of different murmurs, which is really important to help to differentiate which is which. So venous return has an effect on intensity of murmurs. Okay, so almost all murmurs will increase when there's an increase in blood flowing back to the body. So increased preload and some of the maneuvers that increase your preload or increase your... venous return are going to be squatting, leg raise, laying down. And then they're also going to decrease. Most of your murmurs will decrease with decreased venous return. So decreased preload, so standing Valsalva maneuver. But there's two oddballs that are not going to follow these rules. And that's going to be mitral valve prolapse and hypertrophic cardiomyopathy. So it makes sense that most murmurs, if there's more blood coming back to the heart, it's going through the stenotic valve, it's regurgiting, it's going to be louder. And if there's less blood, it's going to be more. quiet but mitral valve prolapse and hypertrophic cardiomyopathy due to the patho behind them they're actually the opposite so mitral valve prolapse is going to the murmur duration is going to decrease and the click will be heard later with increased venous return so murmur duration is actually going to decrease with increased venous return rather than the opposite and with decreased venous return less blood coming back to the heart the murmur duration is actually going to get longer and the click is going to be heard earlier And then with hypertrophic cardiomyopathy, increased venous return, more blood coming back to the heart, the murmur is going to decrease in intensity. And with decreased venous return, less blood coming back to the heart, murmur intensity will actually increase. So these are not following the rules. MVP and hypertrophic cardiomyopathy do not follow the rules. So how do you remember that? Really easy way that I came up with. Remember that the MVP hates conforming to the rules. The MVP does not conform to the rules. He hates conforming to the rules. So MVP stands for mitral valve prolapse. HC and hates conforming is going to stand for hypertrophic cardiomyopathy. Here's the MVP right here saying, nope, I will not follow these rules over here. And the rules of course are increased venous return, will increase murmur intensity, decrease venous return, decrease murmur intensity. He said, nope, I'm not following those rules. I'm the MVP and I hate conforming to the rules. So just another easy way I came up to remember that. So if you can remember that, you're going to know how all of these maneuvers are going to affect it. All of the different, how these maneuvers affect all the different murmurs. So really easy way to remember that. Just remember, the MVP hates conforming to the rules. Alright, so the third trick that I want to go over, the third tip, is going to be differentiating between left and right-sided murmurs. So, right-sided murmurs are actually going to sound almost exactly like left-sided murmurs. So, there's a couple things that you can, that'll help you to differentiate between the two. Because otherwise, aortic stenosis is going to sound just like pulmonary stenosis. So, the first way you know how to tell the difference is based upon their location. So, they're happening in different parts of the heart. So they're going to be best heard at different parts of the thorax. So for instance, aortic stenosis will be best heard in the right upper sternal border, the aortic area, while pulmonic stenosis will be heard in the left upper sternal border. So you just kind of have to memorize these locations if you're going to use this method. And then the other way to differentiate, and I feel the easier way, is remember right-sided murmurs are going to increase in intensity with inspiration, and left-sided murmurs decrease in intensity. The way that I remember that is I remember Rinspiration. So right-sided inspiration increase. I just remember the term Rinspiration. And as soon as I think of right-sided, I remember inspiration increases right-sided murmurs. Just remember that word Rinspiration. It doesn't sound like it's that useful, but it's one of those things I've just never forgotten over the years. And I always remember right-sided murmurs increase with inspiration. So Rinspiration, really easy way to remember. Even when you're auscultating, so when you're actually seeing these patients, not just on an exam, and you tell them to take in a deep breath, if the murmur gets louder, it's likely a right-sided murmur. So if you're auscultating, and because the key thing to note about the location is it's not like aortic stenosis is only going to be heard in the aortic area. It's just heard best there. Sometimes it's hard to tell the difference. And with this, you tell them to take in a deep breath, and all of a sudden it gets louder. You're like, all right, so maybe this is actually pulmonary stenosis rather than aortic stenosis. So. Just a couple different ways to differentiate right and left-sided murmurs. And then one final note, and this always helped me when I was actually doing my OSCEs and things like that. If you ever forget where you're auscultating or they say, go ahead and auscultate the pulmonary area or auscultate the tricuspid area, and you're like, oh, I can't remember where that is on the heart, just remember this. All patients eagerly take medicine. So that's going to be your aortic area, which is going to be the right. upper sternal border at the right second intercostal. And then P, which stands for patience, is going to be your pulmonic. So that's the left upper sternal border at the left second intercostal. Herb's point, which is eagerly, third intercostal, just the left of the sternal border. Tricuspid, which is going to be take, it's going to be your fourth or around the fourth or fifth intercostal, just left of the sternal border. And then finally mitral, which stands for medicine with this. is going to be at the fifth intercostal at the midclavicular line so if you remember that and you can start up at your right upper sternal border you can always remember all patients eagerly take medicine and then just work your way across the thorax there and that can help you when you're actually auscultating all right so let's actually get into our murmurs here we're going to start with aortic stenosis okay so aortic stenosis it's a narrowing of the um of the aortic valve which is going to lead to restricted blood flow from the left ventricle to the aorta and it can lead to left ventricular hypertrophy and even potentially heart failure. So this is just taking a look here. So this is aortic valve stenosis. This is a valve that's been damaged for whatever reason, which we'll go over in a minute. And this is a normal valve here. So you can see when it's open, nice wide open, the blood can get through. And when it closes, it's completely flush. It's completely shut closed. There's no blood potentially regurgiting back. And then you can see here with aortic valve stenosis, you can see the valve does not open as wide, not as much blood is getting through. And then even when it closes in some cases, it doesn't completely close shut. So you can potentially have some regurg. So that's what that's going to look like on an exam. Remember, this is your most common valvular disease. And then you can do what I did in clinicals. And my preceptor would ask me what murmur I heard. And I had no idea what it was. Just say aortic stenosis. And there's like a 50-50 chance you'll be right. Because it is very common. It's your most common of all the valvular diseases. So as far as the etiology, it's really just two things you need to know. These patients are young. relatively young, under 70, you should be thinking of congenital valve abnormality like bicuspid valve. So young under 70, congenital valve abnormality. Old over 70, you should be thinking calcifications. Focus on those two because those are the most common causes. It's rheumatic heart disease is another possible cause, but not as common as like the bicuspid valve and calcification. So really just focus on those two. That's most likely what you'll be asked on an exam. Now, clinical manifestations, I'm going to kind of be brief on the clinical manifestations, the treatment, because they all kind of overlap. They're all very similar. The treatment for almost all of these is going to be surgical in most cases. And then another thing I'm not going to go over is your diagnosis because it's almost always echo. Echo is going to be your best, least invasive test. So I'm not going to focus on that because they're not going to ask you on it because it's pretty much the same across the board. So I'm just going to focus on what's important. So as far as clinical manifestations for adductor stenosis, the one you'll hear about most commonly is going to be something I say ash to help you remember it, but it's angina, syncope and heart failure. Now, it's important to note that these symptoms are typically only seen at the end stages of aortic stenosis. And once these present, patients really only have about two to five years of life left without valve replacement. So while you'll probably be asked this on a vignette, you may not see it in real life because these are patients really at the end stages of aortic stenosis. Now, the one you'll most likely really experience in real life is probably going to be the more common symptom, which is going to be dyspnea on exertion. So a patient that comes in, they're exercising, and for some reason they're starting to get shortness of breath, maybe a little bit of chest pain. It's more common than the late stages. but ash is probably what you'll be asked on a vignette now on the physical exam the murmur of aortic stenosis is uh systolic so it's between s1 and s2 it's crescendo decrescendo and what that means is that the murmur starts shortly after the first heart sound slowly increases until about mid-systole then decreases in intensity and ends just before the second heart sound so louder louder louder then softer And it's best heard at the right upper sternal border, which of course is the aortic area, the right second intercostal area. So this is what crescendo decrescendo looks like. You can see S1 and S2. Remember, this is going to go up, up, up, up, peaks at about mid systole, and then down, down, down, down, and right before S2. So that's crescendo decrescendo, up and then down. So that's what that looks like. And remember, you know this is systolic because is it in misprarcts died? It is not. So you know it's a systolic, not a diastolic murmur. So just remember that. And then it's also going to radiate to the carotid, which is really important. So you can actually auscultate this in the patient's carotid as well and hear the murmur in addition to at the right upper sternal border. So remember that too, because that is important. And there's another physical exam finding that I'll go over. It's known as pulsus parvis et tardis. So parvis in Latin means weakened, and then tardis means late. So the pulse in these individuals is going to be weakened. It occurs late. And, uh... It makes sense because you have blood throwing through the stenotic valve, so the heart beats, but it has to push through the small valve, not as much as getting out, which both delays the pulse and weakens it. Now, treatment, very simple. Valve replacement is going to be definitive, and that's really what these patients need in the end stages. Otherwise, unfortunately, it can be fatal. So let's move on to aortic regurgitation. So aortic regurgitation, also known as aortic insufficiency. So this is an insufficiency with the aortic valve leaflets and due to this insufficiency they have trouble the valve leaflets have trouble remaining closed during diastole which results in a portion of the blood leaking back from the aorta into the left ventricle that's what this looks like here you can see the left ventricle here and then you can see this weakened aortic valve which you can kind of see this opening here so it doesn't completely close shut so some of the blood is going to regurgitate back now etiologies Chronic etiologies, it's going to be most common cause in developing countries is going to be rheumatic heart disease. And then acute, it's going to be endocarditis. You can see this in an aortic dissection as well as an acute MI. So a lot of times in an acute MI, you'll actually auscultate and hear aortic regurgitation. So chronic again, developing countries, rheumatic heart disease, acute endocarditis, aortic dissection, and an acute MI for aortic regurgitation. Clinical manifestations. A lot of times these patients are going to be asymptomatic, but in severe cases, they may develop angina, dyspnea, other symptoms of heart failure. And the physical exam. So remember, this is part of Ms. Prartz. It's the AR in Mrs. Prartz. So we know it's diastolic. And then it's a decrescendo murmur, which I'm going to show you in a minute, that's best heard at the left upper sternal border. And it's also known as a high-pitched murmur, sometimes described as a blowing murmur. So at the left upper sternal border. Second intercostal space. So this is what decrescendo looks like. You can see it actually starts at the maximal intensity at S2 and then decreases, decreases, decreases, and then completely stops before the S1 heart sound. So that's decrescendo. It's basically just decreasing. So that's a diastolic decrescendo murmur. And there's actually a few physical exam findings in a regurgitation that I'm going to go over that I feel like you do need to know because there's a good chance you might get a question. So in addition to the murmur, there's a few different things. So a couple of the first ones. Bounding pulses. And this is going to be due to the... they're going to have this strong pulse, bounding pulse. The reasons that these patients have this bounding or strong pulse is because they have backflow from aortic regurgitation, which in turns increases your stroke volume. So more blood coming out, more volume being expelled during systole. That's basically just going to increase the strength of the pulsation. So you have this bounding or strong pulse. Then the other one, then the ones that I'm going to go over from here on out, including Quenky's pulses, are all going to be related to the widened pulse. pressure that you'll see in aortic regurgitation. So remember, pulse pressure is the difference between systolic and diastolic blood pressure. So wide pulse pressure is normally a difference greater than 60. So say a patient had 120 over 50 blood pressure, that's a difference of 70 pulse pressure, which would be a widened pulse pressure. So let's go over some of the causes from this widened pulse pressure in aortic regurgitation. First one is going to be quinkies pulses. So quinky pulse, it's a capillary pulsation in the fingertips or nail beds. and then the way that i remember quinky's pulses is that i remember the sentence you can see quinky in the pinky because remember it's a capillary pulsation in the fingertips or nail bed so you just remember you can see quinky in the pinky like your pinky finger and you can remember that all right so a couple more that i think you should be familiar with because i do remember getting asked these again maybe you'll get one question maybe you won't but there's they're pretty easy to remember so let's just kind of go over quickly some of the other signs so corrigan or water hammer pulse This is a rapid rising pulse, forceful and strong, that rapidly collapses. And you can test this by palpating the radial pulse with the patient's arm at their side and then having them lift the arm while still palpating the pulse, which will accentuate the water hammer pulse. So I always remember, core again, raise the hand. Core again, raise the hand, because you remember you're palpating the radial, raising the hand up. All right, two more. Dumous set sign. All dumous set sign is these patients will be sitting there and their head actually bobs up and down with each heartbeat. They're going to be... bobbing up and down and up and down. So that's Demoset's sign. And then Mueller's sign, you're going to look at the uvula. In any of these patients, the uvula is kind of going to be dancing around. So it has this systolic pulsation of the uvula, and that's Mueller's sign. So those are some of the physical exam findings I think are important. And then really quickly, treatment. Surgical is going to be definitive, like all of these. And then you can also use medical management with afterload reducers, ACEs, ARBs, hydralazine. Do not focus on the treatment for these, because like I said, they're all very similar. and there's not much that they can ask you on. It's basically just surgery for most of them. I'll mention a few of the other ones, but don't focus, I would not focus too much on your clinical manifestations or the treatment or the, actually, I'm sorry, don't focus too much on the treatment or the diagnosis because they're all pretty similar with all of them. All right, so let's move on to mitral regurgitation. So mitral regurgitation is a valvular disorder where there's abnormalities in any part of the mitral valve apparatus. That includes the leaflets, papillary muscles chord a tendon a and because of this abnormality you have this resultant retrograde blood flow from the left ventricle back into the left atrium which is going to lead into lead to increased pressure in the atrium also dilation of the atrium now as far as etiologies let's take a quick look at that so this is a normal mitral valve here and then you can see here it's regurgiting back into the atrium here because of these the the insufficiency that you see here so that's mitral regurgitation etiology is mitral valve prolapse MVP most common cause in the US that's the one you should really focus on most common cause in the US and as far as in developing countries you'll you'll see rheumatic heart disease as being one of the more common causes but here in the US remember MVP that's likely what you'll be asked on the question and then also be aware there are some other causes like infective endocarditis some medications like ergotamines that are in migraine medications bromo cryptine and cabergoline which are meds used in primarily in hyperprolactinemia, but focus on the high yield ones. So MVP and then rheumatic heart disease, really MVP the most of all of them. Clinical manifestations, dyspnea is common. They may have hypertension. But then the important one is that these patients may actually develop AFib. They can develop atrial fibrillation, which is due to the enlargement of the atrium. So any condition that dilates or enlarges the atrium like mitral regurg, mitral stenosis, whatever the condition is, if there's dilation of the atrium, you should know that these patients are going to be at a higher risk for AFib because stretching of the atrium leads to multiple reentrant circuits that can coexist as well as introducing fibrosis. All of this can lead to conduction abnormalities and potentially AFib. So I'd say of all of the clinical manifestations, AFib is the one that you should really focus on and remember because that's unique about this. as well as some of the other ones with the atrial problem. So AFib and mitral regurgitation is possible. Now, moving on to the physical exam, the classic murmur. for mitral regurgitation is a hollow systolic murmur that's best heard at the apex which is the bottom of the heart that's the mitral area so always remember all patients take all patients eagerly take medicine you can remember where the mitral is but that's the bottom of the heart and then what a hollow systolic means is that the murmur has the same intensity throughout systole there's no peak no decrease in the intensity no increase it's just regular flat rigid the intensity does not vary so you can see straight across the board hollow systolic rigid regular nothing going up or down no peaks or valleys and then it also radiates to the axilla now the way that I remember that this is a hollow systolic murmur and radiates to the axilla so remember mitral regurgitation mostly rigid or regular that helps me remember hollow systolic it's a regular rigid it doesn't go up and down just straight across and then I also remember mostly radiates because it radiates to the axilla I don't know that helped me hopefully it helps you too okay now treatment this is going to be pretty straightforward as all of these surgical is going to be your definitive treatment for mitral regurgitation and then you can also have symptomatic control with afterload reduces aces arbs nitrates as well okay so moving on to mitral stenosis okay so mitral stenosis is going to be an obstruction of blood flow across the mitral valve from the left atrium to the left ventricle and due to the narrowed mitral orifice due to the stenotic valve and mechanical obstruction you're going to have increased pressure in the left atrium which is going to back up into the pulmonary vasculature eventually into the right side of the heart which can potentially lead to heart failure and more progressive disease with mitral stenosis and this is a look at what that actually looks like here you can see it's just a narrowing of the valve so it's just an idea of what that would look like in real life now etiologies remember one thing and that's going to be a rheumatic heart disease mitral stenosis rheumatic heart disease remember that it's the most common cause of mitral stenosis again rheumatic heart disease mitral stenosis do not forget that it can also be caused from calcifications it can be congenital honestly just remember rheumatic heart disease that's what you need to focus on okay so clinical manifestations this one actually has some high yield clinical manifestations that you need to know unlike some of the other murmurs that really didn't this one actually has a few that you should know now afib again for the same reasons that i went over in mitral regurg you These patients can develop AFib due to the increased pressure, increased size of the atrium. But the couple of unique ones that you really should know that I remember being asked in school. One is hoarseness. This is also known as Ortner syndrome. So why would you get hoarseness and mitral stenosis? So let's take a look here. The reason is as the left atrium enlarges in mitral stenosis, you can see the atrium down here. It actually can compress. You can see right here. you have the left recurrent laryngeal nerve, which is coming down here. You can see it wrapping around there. As this enlarges, it can actually start to push on the nearby recurrent laryngeal nerve, which can cause hoarseness in these patients. So really remember that one because you may get a patient who has all of these non-specific symptoms. They have hoarseness, but they also have a little bit of dyspnea, maybe some angina, and you're wondering, what do those all have to do with each other? They may have mitral stenosis. Remember that Ortner syndrome. That is important because sometimes they'll try to trick you with these types of things. And it's not really tricking because it can really happen, but you just need to be familiar with that. And the other thing is something known as mitral fasces or fasces. I don't know if I'm pronouncing that right, but I always said mitral fasces. So it really only happens when these patients have developed severe mitral stenosis, but it's from the pulmonary hypertension and diminished cardiac output in patients with mitral stenosis. They can develop this cutaneous vasodilation. You can take a look at that there. It results in this purplish. pinkish hue in their cheeks um these like rosy cheeks and it's just due to the severe mitral stenosis leading to this diminished cardiac output and this cutaneous vasodilation so that's what that looks like here this can be from mitral stenosis known as mitral fasces or mitral faces okay so physical exam all right so these patients are going to have remember ms is going to stand for miss and miss parts so we know this is going to be a diastolic you It's a rumbling murmur and it's best heard at the apex, again, bottom of the heart. That's the mitral area. And then the other really important thing is that mitral stenosis has an opening snap. And this is due to the mitral valve being forcefully open due to the high pressure. And the way that I remember opening snap is that I remember mitral stenosis MS, opening snap OS equals MSOS. And what does MSOS stand for? It's Microsoft is your operating system. Microsoft is an operating system. So MSOS, MSOS, mitral stenosis opening snap. That one really helped me. I never forgot that one. So hopefully that makes sense to you. But Microsoft is an operating system. So MSOS. mitral stenosis opening snap so hopefully you won't forget that one and then treatment these patients you can actually do what's known as a percutaneous balloon valvuloplasty preferred over valve replacement especially in younger patients and because i mentioned this a couple times already so let's actually take a look at what this is it's exactly what it sounds like they introduce this deflated small balloon it's guided by a catheter and they introduce it into the stenotic valve and they inflate it over the valve to open it up so you see it comes in here the guide wire put the balloon inside they blow it up and this kind of just stretches it out so it's not as as tight and stenotic in that area and there's a few different valve abnormalities you can actually use this in it's obviously less invasive than surgery and sometimes can be used initially sometimes it can be used as a bridge to surgery sometimes like in mitral stenosis and maybe all these patients need but a lot of times they still wind up needing surgery as well but remember mitral stenosis in younger patients particularly you can do percutaneous balloon valvuloplasty over valve replacement all right so let's move on to mitral valve prolapse this is going to be when the two valves of the two valve flaps of the mitral valve don't close properly instead of closing and having this flush point they're going to bulge or prolapse up into the the left atrium so we can see them bulging up here instead of closing nice nice and flush here so nothing's going on there they're actually going to bulge up and that's mitral valve prolapse and there's a slight predominance in younger women Often what you'll see in a vignette is a young woman who presents with anxiety, chest pain, palpitations, other associated autonomic dysfunction. I'll go over that in a minute, what that's known as and things like that. But remember that very well may be in a vignette. And then also remember, as we went over before, MVP is going to be the most common cause of mitral regurgitation in the U.S. That's very important as well. Okay, so etiologies, there's primary and there's secondary MVP. So primary MVP is going to be when degenerative disease is present, which is known as myxomatous degeneration, but there's no associated connective tissue disease. So degenerative disease like this myxomatous degeneration, but no associated connective tissue disease. Secondary, same thing, but there is going to be a connective tissue disease present. The one you really should be familiar with that's probably going to come up in the vignette is Marfan syndrome, which can cause MVP. But you also may see it in Ehlers-Danlos, but Marfan's more commonly asked. That's the one you should really be familiar with. So secondary is when that connective tissue disease is present that's leading to mitral valve prolapse. So clinical manifestations, most of the time these patients are actually going to be asymptomatic. But because of the vignettes that are common with MVP, you should be familiar with something known as MVP syndrome. And I went over this before, but you have these symptoms consisting of anxiety palpitations dizziness and these this may be seen in patients with mitral valve prolapse but it's important to note and there's a good chance you're going to have a question on this but it doesn't mean that it's actually very common and if you read the this the the data and the actual information on up to date as of right now this mitral valve prolapse syndrome it's not actually as common as they once thought in a lot of studies there was problems with the studies, they were flawed, and they're thinking it's not as common as they initially thought, doesn't mean you're not going to get a question presenting it this way. So be familiar. It can happen, but just not as commonly as they thought. The studies were pretty flawed, and they're kind of going back on some of what they've said about that. So anyways, on physical exam, there's two things for the esculptatory findings in a patient with MVP that you need to know. So one is that they're going to have this mid to late systolic ejection click. That's huge. Don't forget that it's probably the most important thing to know about MVP, and it's from the snapping of the mitral chordae when the valve prolapses into the atrium. So that's that mid to late systolic ejection clip. And then also be aware that these patients very well, very likely may also have mitral regurgitation murmur present, because remember the association between the two. Now, the other thing you need to remember, because I haven't gone over this in any of the other ones, because I didn't need to, because you know the rules, is that MVP, again, remember, it hates conforming to the rules. so mvp you're going to see the opposite increased preload like raising the legs more blood into the heart these patients are actually going to have a shortened length of murmur and causing the click to be delayed so it happens later and then decreased preload of course is going to cause the murmur duration to increase and the click will occur earlier so remember this is the only one i'm going over this because everything else remember increase venous return increase murmur Decreased venous return, decreased intensity of the murmur, except for MBP and hypertrophic cardiomyopathy. So remember that. because that'll help you differentiate it from some of the other ones now as far as treatment asymptomatic you're just going to reassure these patients which will be most of them honestly most patients will not have a lot of symptoms with mvp mvp if they do have severe mitral regurgitation they may need surgery to repair the valve and then for some of the autonomic dysfunction symptoms you can use beta blockers to help with that all right so let's move on to the the right side of the heart I'm going to keep these pretty brief because there's not a lot to know compared to the left side of murmurs. And the fact of the matter is, is that they overlap with the left side of murmurs. So if you already know aortic stenosis, then you pretty much know pulmonic stenosis, at least as far as the physical exam findings. So I'd say know the left side of murmurs really well, and then you'll know the right side of ones because they're similar. Just remember they increase with inspiration. And they're most of the time not tested on as frequently, but let's go over them real quick. So pulmonic stenosis. It's going to be an outflow obstruction of the right ventricle due to a stenotic pulmonary valve. And the other thing too with either all of the pulmonary conditions, pulmonic stenosis, pulmonary regurg, is that these are very often congenital heart diseases. They're very commonly seen in children. So this is what pulmonary valve stenosis will look like here. We can see it's just a stenotic valve instead of being kind of opened up here that's like nice and tight, and it's just stenotic. It's just stenosis. That's pulmonary stenosis. It's seen in about 7% of children with congenital heart disease. Like I said, it's very common in children. The pulmonic ones are, you know, more commonly seen in children. Now, etiologies, it can be an isolated lesion, but it's also commonly associated with Tetralogy of Fallot. Congenital Rubella Syndrome is a big one, and Newnan Syndrome as well. Clinical manifestations, mostly asymptomatic most of the time, but it's possible to develop exertional dyspnea other symptoms of right-sided heart failure and then the physical exam well do you know what aortic stenosis sounds like you probably remember that's a systolic crescendo decrescendo so what do you think pulmonary pulmonic stenosis is gonna sound like systolic crescendo decrescendo only difference is it's gonna be best heard at the left upper sternal border the pulmonic area instead of the right upper sternal border like in aortic stenosis and then it can radiate to the neck just like an aortic stenosis but remember it's going to increase in intensity with inspiration so rinspiration and that's how you'll differentiate it from aortic stenosis in addition to the location so remember that treatment mild disease just observe these patients if they do have moderate to severe disease you can perform a balloon valvuloplasty or in some severe cases you have to have a surgical replacement of the the valve so pulmonary regurgitation this is going to be a valvular abnormality of the pulmonary valve It's going to lead to backflow from the pulmonary artery back into the right ventricle. So we can see that here. You have the pulmonic valve that's going to lead to backflow back into the right ventricle here. So that is pulmonary regurg. And in severe cases, this can lead to right-sided heart failure. Etiologies can often be, and again, like I said, all the pulmonary ones are often congenital. It can be seen alongside tetralogy of fallot, endocarditis, rheumatic heart disease. Clinical manifestations, again, generally they're going to be asymptomatic. Unless it's severe, then they can develop symptoms of right-sided heart failure. But most of the time, these patients will be pretty much asymptomatic. Physical exam, just like its cousin aortic regurg, this is going to be a diastolic decrescendo murmur, but it's going to be heard at the left upper sternal border, the pulmonic area. And then remember, on all of these right-sided ones, increase in intensity with inspiration, rinspiration. So that's the difference there. And then the other thing that you need to know for this, because I got stumped on a question with this, they may not call it pulmonary regurgitation. So you may have a question and you'll look at the vignette and you'll say, okay, I know this is pulmonary regurg. You look at the answers and pulmonary regurg isn't there. And you're like, what? But what may be there is something known as a Graham steel murmur. So the murmur is also known as a Graham steel. And this is how it's spelled. S-T-E-E-L-L. I didn't make a spelling error there. And that's what it's spelled. Like in the way that I remember that now, back then, I think I may have forgotten it. I may have gotten it wrong. But remember, Graham Steele sounds like the Man of Steel, sounds like a superhero. And you can remember Graham Steele is protector of the realm. So Graham Steele, protector of the realm. So remember, protector of the realm, PR stands for pulmonary regurgitation. Graham Steele, he's a superhero. He's protector of the realm, PR, pulmonary regurg. So hopefully that'll help you. If you do get that question, you can remember that's pulmonary regurg. Now, as far as treatment observation, treat the underlying cause in a lot of cases. So whether it's Tetralogy of flow, endocarditis, just treat the underlying cause most of the time. Otherwise, it's just observation if they're asymptomatic. Okay, so moving on to tricuspid stenosis. We are getting there. We're almost done. Okay, so this is actually pretty rare, and it's usually found along with either tricuspid regurge or other valvular lesions. You're not going to find this one as an isolated lesion. It's basically just a stenotic tricuspid valve due to some underlying condition. and it leads to blood backing up in the right atrium eventually leading to a right atrial dilation or enlargement and potentially if it's left untreated it can lead to right-sided heart failure so you can see that's what this looks like here you have this um this tricuspid valve that is nice and stenotic here nice and tight instead of being wide open like this just a little bit of blood is able to get through so you can potentially have blood backing up into this right atrium and you can see how it's dilated here compared to to this right atrium here because not as much is getting through So you have increased pressure there and some of the problems associated with that. Now, etiologies really should just focus on rheumatic heart disease. It's the most common cause of tricuspid stenosis. There's also some iatrogenic causes like from radiation therapy, fibrosis from endocardial pacemaker leads, but really just focus on rheumatic heart disease. Don't waste your time with the less common things. Focus on the high yield stuff. So clinical manifestations, again, like all of these, fatigue, dyspnea. Just remember this is normally not an isolated lesion so you're going to have symptoms from not only tricuspid stenosis but maybe mitral aortic valve disease. So overall the clinical manifestations are not too specific really like all of these so I just wouldn't focus on the clinical manifestations. Let's move on to physical exam. So the murmur of tricuspid stenosis is going to be a diastolic murmur. It's best heard at the left lower sternal border which again is the tricuspid area. Then the other thing that you should remember just like its cousin mitral stenosis. It also has an opening snap So like I said, if you know the left side really well, you're gonna know the physical exam for the right side really well So just really remember your left side and then you'll always know the the right side because like I said, they're the same The only difference here is that the opening snap normally occurs a little later than what's heard in mitral stenosis And then again remember the only difference is going to be a RIN spiration. It's going to increase with inspiration and then it's heard in the the tricuspid area treatment surgery is going to be definitive and then medications can be used to decrease right atrial overload like diuretics okay so tricuspid regurg this is going to be it and then we'll be done this is going to be the back flow of blood into the right atrium during systole and only severe cases cause any problems like right-sided heart failure most people aren't going to actually have any hemodynamic consequences from tricuspid regurg And unlike some of the other right-sided murmurs, if you take a look at that here, so you can see a normal tricuspid valve, and then you can see over here you have this tricuspid valve that's actually going to have this regurg here for the blood backing up into the atrium there. So this one's actually pretty common, and a small degree of tricuspid regurg is actually seen in about 70% of adults. Most patients will be asymptomatic, but it's pretty common in... a lot of the population actually. So compared to some of the other ones which are pretty rare, this one's actually pretty common. As far as etiologies, Epstein's anomaly is the most common congenital heart disease that causes the condition. It can also be seen in infective endocarditis, Marfan syndrome, as well as some iatrogenic causes like from pacemaker leads. And even when endomyocardial biopsy is performed, sometimes you can have tricuspid regurg. Clinical manifestations, most patients are going to be asymptomatic. Of course, don't waste your time on this. You know, in some of the severe cases, you may have those nonspecific symptoms of dyspnea, exercise intolerance, etc. Okay, physical exam. Again, remember, just like your left-sided murmur, you can figure it out with the right. So remember, mitral regurgitation, mostly regular, mostly rigid. So this is obviously going to be just like that. In tricuspid regurg, it'll be a hollow systolic murmur. But this one's going to be best heard at the tricuspid area. So that's the difference there. and then of course remember where inspiration is going to increase with inspiration treatment surgical definitive diuretics for fluid overload okay so that's it for the murmurs for your nccp blueprint i know i went through it kind of quickly but a lot of it had overlap and i didn't want to waste your time with too much on on those things so let's do five quick questions and then we will wrap it up okay so one name all of the diastolic murmurs remember miss prarts died so that's going to be ms mitral stenosis pulmonary regurg aortic regurg and tricuspid stenosis. Those are your diastolics. If it's not in that sentence, Ms. Prarts died, you know it is a systolic murmur. Describe the murmur of aortic stenosis. murmur of aortic stenosis is going to be systolic crescendo decrescendo up then down and then it's going to radiate to the carotids number three what is the most common cause of mitral regurgitation in the u.s most common cause of mitral regurg in the u.s is going to be mvp mitral valve prolapse describe quincy's pulse quincy's pulse remember quincy is seen in the pinky Capillary pulsation in the fingertips or nail beds seen in aortic regurg. Squinky is seen in the pinky. What is the most common cause of mitral stenosis? Most common cause of mitral stenosis, you have to know this one, is going to be rheumatic heart disease. Okay, so that is it for murmurs. Thank you so much. I appreciate everything, every comment, every like. It really means so much to me. If you haven't checked out the podcast, please do. Cram the Pants on Apple Podcasts, Spotify. pretty much anywhere you listen to your podcast that should be on there. Please send me a message. Let me know how this is helping you. And as always, good luck on your pants, your pannery, your EORs, and good luck in PA school.

So really quickly again, like I do in every video, thank you so much for the comments, the new subscriptions, the likes. I really, really appreciate it. So thank you again for that.

So all right, before we get started with murmurs and breaking down what you need to know for each individual one, I want to review a few areas that will help you not only get the question right of the exam but also to help you in real life so first thing that i want to review is um uh differentiating between systolic and diastolic murmurs and really easy way i found to memorize them for the exam okay so there's um systolic and diastolic so systolic murmurs are going to occur between s1 and s2 heart sounds and as we can see here we have our systolic murmurs s1 when the mitral and tricuspid close and then s2 here where the aortic and pulmonary valve close so this is systolic falling in between s1 and s2 and then we have the systolic murmurs which are aortic stenosis pulmonic stenosis mitral regurg tricuspid regurg and mvp or mitral valve prolapse then we have our diastolic murmurs it's going to occur after s2 between s2 and s1 so diastolic is going to occur right here right after the aortic and pulmonary valve close and before s1 here so this is where diastolic is going to fall that's where your murmurs will be heard Now, how do you remember them? Let's also go over what the diastolic murmurs are. So, it's mitral stenosis, pulmonary regurg, aortic regurg, and tricuspid stenosis.

So, a really easy way I found to remember them, and this is what I came up with. So, how do you remember which is systolic and which is diastolic? Really, obviously, just for the exams, but what I remember is the sentence, Ms. Prartz died.

Ms. Prartz died, and what does that stand for? So, Ms. Prartz died. Here she is over here. Unfortunately, she died. So, Ms. Prartz died, Ms. Miss. stands for mitral stenosis.

PR in Prarts stands for pulmonary regurgitation. AR stands for aortic regurg, and TS stands for tricuspid stenosis, and then died stands for diastolic. So any one of these in Ms. Prarts died is going to be a diastolic murmur.

If it's not in the sentence Ms. Prarts died, it's not diastolic, and therefore it's systolic. So if you can remember this, you can remember all the diastolic murmurs, and therefore you know all the systolic murmurs too, because if it's not here, it's a systolic murmur. So just a really easy way to remember which is systolic and which is diastolic.

So that's an easy way for you to remember that. Okay, so the second tip is related to venous return and its effect on the intensity of different murmurs, which is really important to help to differentiate which is which. So venous return has an effect on intensity of murmurs. Okay, so almost all murmurs will increase when there's an increase in blood flowing back to the body.

So increased preload and some of the maneuvers that increase your preload or increase your... venous return are going to be squatting, leg raise, laying down. And then they're also going to decrease. Most of your murmurs will decrease with decreased venous return.

So decreased preload, so standing Valsalva maneuver. But there's two oddballs that are not going to follow these rules. And that's going to be mitral valve prolapse and hypertrophic cardiomyopathy. So it makes sense that most murmurs, if there's more blood coming back to the heart, it's going through the stenotic valve, it's regurgiting, it's going to be louder.

And if there's less blood, it's going to be more. quiet but mitral valve prolapse and hypertrophic cardiomyopathy due to the patho behind them they're actually the opposite so mitral valve prolapse is going to the murmur duration is going to decrease and the click will be heard later with increased venous return so murmur duration is actually going to decrease with increased venous return rather than the opposite and with decreased venous return less blood coming back to the heart the murmur duration is actually going to get longer and the click is going to be heard earlier And then with hypertrophic cardiomyopathy, increased venous return, more blood coming back to the heart, the murmur is going to decrease in intensity. And with decreased venous return, less blood coming back to the heart, murmur intensity will actually increase.

So these are not following the rules. MVP and hypertrophic cardiomyopathy do not follow the rules. So how do you remember that?

Really easy way that I came up with. Remember that the MVP hates conforming to the rules. The MVP does not conform to the rules. He hates conforming to the rules. So MVP stands for mitral valve prolapse.

HC and hates conforming is going to stand for hypertrophic cardiomyopathy. Here's the MVP right here saying, nope, I will not follow these rules over here. And the rules of course are increased venous return, will increase murmur intensity, decrease venous return, decrease murmur intensity.

He said, nope, I'm not following those rules. I'm the MVP and I hate conforming to the rules. So just another easy way I came up to remember that.

So if you can remember that, you're going to know how all of these maneuvers are going to affect it. All of the different, how these maneuvers affect all the different murmurs. So really easy way to remember that.

Just remember, the MVP hates conforming to the rules. Alright, so the third trick that I want to go over, the third tip, is going to be differentiating between left and right-sided murmurs. So, right-sided murmurs are actually going to sound almost exactly like left-sided murmurs. So, there's a couple things that you can, that'll help you to differentiate between the two. Because otherwise, aortic stenosis is going to sound just like pulmonary stenosis.

So, the first way you know how to tell the difference is based upon their location. So, they're happening in different parts of the heart. So they're going to be best heard at different parts of the thorax.

So for instance, aortic stenosis will be best heard in the right upper sternal border, the aortic area, while pulmonic stenosis will be heard in the left upper sternal border. So you just kind of have to memorize these locations if you're going to use this method. And then the other way to differentiate, and I feel the easier way, is remember right-sided murmurs are going to increase in intensity with inspiration, and left-sided murmurs decrease in intensity. The way that I remember that is I remember Rinspiration. So right-sided inspiration increase.

I just remember the term Rinspiration. And as soon as I think of right-sided, I remember inspiration increases right-sided murmurs. Just remember that word Rinspiration. It doesn't sound like it's that useful, but it's one of those things I've just never forgotten over the years. And I always remember right-sided murmurs increase with inspiration.

So Rinspiration, really easy way to remember. Even when you're auscultating, so when you're actually seeing these patients, not just on an exam, and you tell them to take in a deep breath, if the murmur gets louder, it's likely a right-sided murmur. So if you're auscultating, and because the key thing to note about the location is it's not like aortic stenosis is only going to be heard in the aortic area. It's just heard best there.

Sometimes it's hard to tell the difference. And with this, you tell them to take in a deep breath, and all of a sudden it gets louder. You're like, all right, so maybe this is actually pulmonary stenosis rather than aortic stenosis. So. Just a couple different ways to differentiate right and left-sided murmurs.

And then one final note, and this always helped me when I was actually doing my OSCEs and things like that. If you ever forget where you're auscultating or they say, go ahead and auscultate the pulmonary area or auscultate the tricuspid area, and you're like, oh, I can't remember where that is on the heart, just remember this. All patients eagerly take medicine.

So that's going to be your aortic area, which is going to be the right. upper sternal border at the right second intercostal. And then P, which stands for patience, is going to be your pulmonic. So that's the left upper sternal border at the left second intercostal. Herb's point, which is eagerly, third intercostal, just the left of the sternal border.

Tricuspid, which is going to be take, it's going to be your fourth or around the fourth or fifth intercostal, just left of the sternal border. And then finally mitral, which stands for medicine with this. is going to be at the fifth intercostal at the midclavicular line so if you remember that and you can start up at your right upper sternal border you can always remember all patients eagerly take medicine and then just work your way across the thorax there and that can help you when you're actually auscultating all right so let's actually get into our murmurs here we're going to start with aortic stenosis okay so aortic stenosis it's a narrowing of the um of the aortic valve which is going to lead to restricted blood flow from the left ventricle to the aorta and it can lead to left ventricular hypertrophy and even potentially heart failure. So this is just taking a look here.

So this is aortic valve stenosis. This is a valve that's been damaged for whatever reason, which we'll go over in a minute. And this is a normal valve here.

So you can see when it's open, nice wide open, the blood can get through. And when it closes, it's completely flush. It's completely shut closed. There's no blood potentially regurgiting back.

And then you can see here with aortic valve stenosis, you can see the valve does not open as wide, not as much blood is getting through. And then even when it closes in some cases, it doesn't completely close shut. So you can potentially have some regurg. So that's what that's going to look like on an exam.

Remember, this is your most common valvular disease. And then you can do what I did in clinicals. And my preceptor would ask me what murmur I heard.

And I had no idea what it was. Just say aortic stenosis. And there's like a 50-50 chance you'll be right.

Because it is very common. It's your most common of all the valvular diseases. So as far as the etiology, it's really just two things you need to know.

These patients are young. relatively young, under 70, you should be thinking of congenital valve abnormality like bicuspid valve. So young under 70, congenital valve abnormality.

Old over 70, you should be thinking calcifications. Focus on those two because those are the most common causes. It's rheumatic heart disease is another possible cause, but not as common as like the bicuspid valve and calcification. So really just focus on those two.

That's most likely what you'll be asked on an exam. Now, clinical manifestations, I'm going to kind of be brief on the clinical manifestations, the treatment, because they all kind of overlap. They're all very similar. The treatment for almost all of these is going to be surgical in most cases.

And then another thing I'm not going to go over is your diagnosis because it's almost always echo. Echo is going to be your best, least invasive test. So I'm not going to focus on that because they're not going to ask you on it because it's pretty much the same across the board.

So I'm just going to focus on what's important. So as far as clinical manifestations for adductor stenosis, the one you'll hear about most commonly is going to be something I say ash to help you remember it, but it's angina, syncope and heart failure. Now, it's important to note that these symptoms are typically only seen at the end stages of aortic stenosis.

And once these present, patients really only have about two to five years of life left without valve replacement. So while you'll probably be asked this on a vignette, you may not see it in real life because these are patients really at the end stages of aortic stenosis. Now, the one you'll most likely really experience in real life is probably going to be the more common symptom, which is going to be dyspnea on exertion.

So a patient that comes in, they're exercising, and for some reason they're starting to get shortness of breath, maybe a little bit of chest pain. It's more common than the late stages. but ash is probably what you'll be asked on a vignette now on the physical exam the murmur of aortic stenosis is uh systolic so it's between s1 and s2 it's crescendo decrescendo and what that means is that the murmur starts shortly after the first heart sound slowly increases until about mid-systole then decreases in intensity and ends just before the second heart sound so louder louder louder then softer And it's best heard at the right upper sternal border, which of course is the aortic area, the right second intercostal area. So this is what crescendo decrescendo looks like.

You can see S1 and S2. Remember, this is going to go up, up, up, up, peaks at about mid systole, and then down, down, down, down, and right before S2. So that's crescendo decrescendo, up and then down.

So that's what that looks like. And remember, you know this is systolic because is it in misprarcts died? It is not.

So you know it's a systolic, not a diastolic murmur. So just remember that. And then it's also going to radiate to the carotid, which is really important.

So you can actually auscultate this in the patient's carotid as well and hear the murmur in addition to at the right upper sternal border. So remember that too, because that is important. And there's another physical exam finding that I'll go over.

It's known as pulsus parvis et tardis. So parvis in Latin means weakened, and then tardis means late. So the pulse in these individuals is going to be weakened.

It occurs late. And, uh... It makes sense because you have blood throwing through the stenotic valve, so the heart beats, but it has to push through the small valve, not as much as getting out, which both delays the pulse and weakens it. Now, treatment, very simple. Valve replacement is going to be definitive, and that's really what these patients need in the end stages.

Otherwise, unfortunately, it can be fatal. So let's move on to aortic regurgitation. So aortic regurgitation, also known as aortic insufficiency. So this is an insufficiency with the aortic valve leaflets and due to this insufficiency they have trouble the valve leaflets have trouble remaining closed during diastole which results in a portion of the blood leaking back from the aorta into the left ventricle that's what this looks like here you can see the left ventricle here and then you can see this weakened aortic valve which you can kind of see this opening here so it doesn't completely close shut so some of the blood is going to regurgitate back now etiologies Chronic etiologies, it's going to be most common cause in developing countries is going to be rheumatic heart disease.

And then acute, it's going to be endocarditis. You can see this in an aortic dissection as well as an acute MI. So a lot of times in an acute MI, you'll actually auscultate and hear aortic regurgitation. So chronic again, developing countries, rheumatic heart disease, acute endocarditis, aortic dissection, and an acute MI for aortic regurgitation.

Clinical manifestations. A lot of times these patients are going to be asymptomatic, but in severe cases, they may develop angina, dyspnea, other symptoms of heart failure. And the physical exam.

So remember, this is part of Ms. Prartz. It's the AR in Mrs. Prartz. So we know it's diastolic.

And then it's a decrescendo murmur, which I'm going to show you in a minute, that's best heard at the left upper sternal border. And it's also known as a high-pitched murmur, sometimes described as a blowing murmur. So at the left upper sternal border.

Second intercostal space. So this is what decrescendo looks like. You can see it actually starts at the maximal intensity at S2 and then decreases, decreases, decreases, and then completely stops before the S1 heart sound.

So that's decrescendo. It's basically just decreasing. So that's a diastolic decrescendo murmur. And there's actually a few physical exam findings in a regurgitation that I'm going to go over that I feel like you do need to know because there's a good chance you might get a question. So in addition to the murmur, there's a few different things.

So a couple of the first ones. Bounding pulses. And this is going to be due to the...

they're going to have this strong pulse, bounding pulse. The reasons that these patients have this bounding or strong pulse is because they have backflow from aortic regurgitation, which in turns increases your stroke volume. So more blood coming out, more volume being expelled during systole.

That's basically just going to increase the strength of the pulsation. So you have this bounding or strong pulse. Then the other one, then the ones that I'm going to go over from here on out, including Quenky's pulses, are all going to be related to the widened pulse.

pressure that you'll see in aortic regurgitation. So remember, pulse pressure is the difference between systolic and diastolic blood pressure. So wide pulse pressure is normally a difference greater than 60. So say a patient had 120 over 50 blood pressure, that's a difference of 70 pulse pressure, which would be a widened pulse pressure.

So let's go over some of the causes from this widened pulse pressure in aortic regurgitation. First one is going to be quinkies pulses. So quinky pulse, it's a capillary pulsation in the fingertips or nail beds. and then the way that i remember quinky's pulses is that i remember the sentence you can see quinky in the pinky because remember it's a capillary pulsation in the fingertips or nail bed so you just remember you can see quinky in the pinky like your pinky finger and you can remember that all right so a couple more that i think you should be familiar with because i do remember getting asked these again maybe you'll get one question maybe you won't but there's they're pretty easy to remember so let's just kind of go over quickly some of the other signs so corrigan or water hammer pulse This is a rapid rising pulse, forceful and strong, that rapidly collapses. And you can test this by palpating the radial pulse with the patient's arm at their side and then having them lift the arm while still palpating the pulse, which will accentuate the water hammer pulse.

So I always remember, core again, raise the hand. Core again, raise the hand, because you remember you're palpating the radial, raising the hand up. All right, two more. Dumous set sign. All dumous set sign is these patients will be sitting there and their head actually bobs up and down with each heartbeat.

They're going to be... bobbing up and down and up and down. So that's Demoset's sign. And then Mueller's sign, you're going to look at the uvula.

In any of these patients, the uvula is kind of going to be dancing around. So it has this systolic pulsation of the uvula, and that's Mueller's sign. So those are some of the physical exam findings I think are important. And then really quickly, treatment. Surgical is going to be definitive, like all of these.

And then you can also use medical management with afterload reducers, ACEs, ARBs, hydralazine. Do not focus on the treatment for these, because like I said, they're all very similar. and there's not much that they can ask you on. It's basically just surgery for most of them.

I'll mention a few of the other ones, but don't focus, I would not focus too much on your clinical manifestations or the treatment or the, actually, I'm sorry, don't focus too much on the treatment or the diagnosis because they're all pretty similar with all of them. All right, so let's move on to mitral regurgitation. So mitral regurgitation is a valvular disorder where there's abnormalities in any part of the mitral valve apparatus.

That includes the leaflets, papillary muscles chord a tendon a and because of this abnormality you have this resultant retrograde blood flow from the left ventricle back into the left atrium which is going to lead into lead to increased pressure in the atrium also dilation of the atrium now as far as etiologies let's take a quick look at that so this is a normal mitral valve here and then you can see here it's regurgiting back into the atrium here because of these the the insufficiency that you see here so that's mitral regurgitation etiology is mitral valve prolapse MVP most common cause in the US that's the one you should really focus on most common cause in the US and as far as in developing countries you'll you'll see rheumatic heart disease as being one of the more common causes but here in the US remember MVP that's likely what you'll be asked on the question and then also be aware there are some other causes like infective endocarditis some medications like ergotamines that are in migraine medications bromo cryptine and cabergoline which are meds used in primarily in hyperprolactinemia, but focus on the high yield ones. So MVP and then rheumatic heart disease, really MVP the most of all of them. Clinical manifestations, dyspnea is common.

They may have hypertension. But then the important one is that these patients may actually develop AFib. They can develop atrial fibrillation, which is due to the enlargement of the atrium.

So any condition that dilates or enlarges the atrium like mitral regurg, mitral stenosis, whatever the condition is, if there's dilation of the atrium, you should know that these patients are going to be at a higher risk for AFib because stretching of the atrium leads to multiple reentrant circuits that can coexist as well as introducing fibrosis. All of this can lead to conduction abnormalities and potentially AFib. So I'd say of all of the clinical manifestations, AFib is the one that you should really focus on and remember because that's unique about this. as well as some of the other ones with the atrial problem. So AFib and mitral regurgitation is possible.

Now, moving on to the physical exam, the classic murmur. for mitral regurgitation is a hollow systolic murmur that's best heard at the apex which is the bottom of the heart that's the mitral area so always remember all patients take all patients eagerly take medicine you can remember where the mitral is but that's the bottom of the heart and then what a hollow systolic means is that the murmur has the same intensity throughout systole there's no peak no decrease in the intensity no increase it's just regular flat rigid the intensity does not vary so you can see straight across the board hollow systolic rigid regular nothing going up or down no peaks or valleys and then it also radiates to the axilla now the way that I remember that this is a hollow systolic murmur and radiates to the axilla so remember mitral regurgitation mostly rigid or regular that helps me remember hollow systolic it's a regular rigid it doesn't go up and down just straight across and then I also remember mostly radiates because it radiates to the axilla I don't know that helped me hopefully it helps you too okay now treatment this is going to be pretty straightforward as all of these surgical is going to be your definitive treatment for mitral regurgitation and then you can also have symptomatic control with afterload reduces aces arbs nitrates as well okay so moving on to mitral stenosis okay so mitral stenosis is going to be an obstruction of blood flow across the mitral valve from the left atrium to the left ventricle and due to the narrowed mitral orifice due to the stenotic valve and mechanical obstruction you're going to have increased pressure in the left atrium which is going to back up into the pulmonary vasculature eventually into the right side of the heart which can potentially lead to heart failure and more progressive disease with mitral stenosis and this is a look at what that actually looks like here you can see it's just a narrowing of the valve so it's just an idea of what that would look like in real life now etiologies remember one thing and that's going to be a rheumatic heart disease mitral stenosis rheumatic heart disease remember that it's the most common cause of mitral stenosis again rheumatic heart disease mitral stenosis do not forget that it can also be caused from calcifications it can be congenital honestly just remember rheumatic heart disease that's what you need to focus on okay so clinical manifestations this one actually has some high yield clinical manifestations that you need to know unlike some of the other murmurs that really didn't this one actually has a few that you should know now afib again for the same reasons that i went over in mitral regurg you These patients can develop AFib due to the increased pressure, increased size of the atrium. But the couple of unique ones that you really should know that I remember being asked in school.

One is hoarseness. This is also known as Ortner syndrome. So why would you get hoarseness and mitral stenosis?

So let's take a look here. The reason is as the left atrium enlarges in mitral stenosis, you can see the atrium down here. It actually can compress.

You can see right here. you have the left recurrent laryngeal nerve, which is coming down here. You can see it wrapping around there.

As this enlarges, it can actually start to push on the nearby recurrent laryngeal nerve, which can cause hoarseness in these patients. So really remember that one because you may get a patient who has all of these non-specific symptoms. They have hoarseness, but they also have a little bit of dyspnea, maybe some angina, and you're wondering, what do those all have to do with each other?

They may have mitral stenosis. Remember that Ortner syndrome. That is important because sometimes they'll try to trick you with these types of things.

And it's not really tricking because it can really happen, but you just need to be familiar with that. And the other thing is something known as mitral fasces or fasces. I don't know if I'm pronouncing that right, but I always said mitral fasces. So it really only happens when these patients have developed severe mitral stenosis, but it's from the pulmonary hypertension and diminished cardiac output in patients with mitral stenosis. They can develop this cutaneous vasodilation.

You can take a look at that there. It results in this purplish. pinkish hue in their cheeks um these like rosy cheeks and it's just due to the severe mitral stenosis leading to this diminished cardiac output and this cutaneous vasodilation so that's what that looks like here this can be from mitral stenosis known as mitral fasces or mitral faces okay so physical exam all right so these patients are going to have remember ms is going to stand for miss and miss parts so we know this is going to be a diastolic you It's a rumbling murmur and it's best heard at the apex, again, bottom of the heart. That's the mitral area.

And then the other really important thing is that mitral stenosis has an opening snap. And this is due to the mitral valve being forcefully open due to the high pressure. And the way that I remember opening snap is that I remember mitral stenosis MS, opening snap OS equals MSOS.

And what does MSOS stand for? It's Microsoft is your operating system. Microsoft is an operating system.

So MSOS, MSOS, mitral stenosis opening snap. That one really helped me. I never forgot that one. So hopefully that makes sense to you.

But Microsoft is an operating system. So MSOS. mitral stenosis opening snap so hopefully you won't forget that one and then treatment these patients you can actually do what's known as a percutaneous balloon valvuloplasty preferred over valve replacement especially in younger patients and because i mentioned this a couple times already so let's actually take a look at what this is it's exactly what it sounds like they introduce this deflated small balloon it's guided by a catheter and they introduce it into the stenotic valve and they inflate it over the valve to open it up so you see it comes in here the guide wire put the balloon inside they blow it up and this kind of just stretches it out so it's not as as tight and stenotic in that area and there's a few different valve abnormalities you can actually use this in it's obviously less invasive than surgery and sometimes can be used initially sometimes it can be used as a bridge to surgery sometimes like in mitral stenosis and maybe all these patients need but a lot of times they still wind up needing surgery as well but remember mitral stenosis in younger patients particularly you can do percutaneous balloon valvuloplasty over valve replacement all right so let's move on to mitral valve prolapse this is going to be when the two valves of the two valve flaps of the mitral valve don't close properly instead of closing and having this flush point they're going to bulge or prolapse up into the the left atrium so we can see them bulging up here instead of closing nice nice and flush here so nothing's going on there they're actually going to bulge up and that's mitral valve prolapse and there's a slight predominance in younger women Often what you'll see in a vignette is a young woman who presents with anxiety, chest pain, palpitations, other associated autonomic dysfunction.

I'll go over that in a minute, what that's known as and things like that. But remember that very well may be in a vignette. And then also remember, as we went over before, MVP is going to be the most common cause of mitral regurgitation in the U.S.

That's very important as well. Okay, so etiologies, there's primary and there's secondary MVP. So primary MVP is going to be when degenerative disease is present, which is known as myxomatous degeneration, but there's no associated connective tissue disease.

So degenerative disease like this myxomatous degeneration, but no associated connective tissue disease. Secondary, same thing, but there is going to be a connective tissue disease present. The one you really should be familiar with that's probably going to come up in the vignette is Marfan syndrome, which can cause MVP.

But you also may see it in Ehlers-Danlos, but Marfan's more commonly asked. That's the one you should really be familiar with. So secondary is when that connective tissue disease is present that's leading to mitral valve prolapse. So clinical manifestations, most of the time these patients are actually going to be asymptomatic. But because of the vignettes that are common with MVP, you should be familiar with something known as MVP syndrome.

And I went over this before, but you have these symptoms consisting of anxiety palpitations dizziness and these this may be seen in patients with mitral valve prolapse but it's important to note and there's a good chance you're going to have a question on this but it doesn't mean that it's actually very common and if you read the this the the data and the actual information on up to date as of right now this mitral valve prolapse syndrome it's not actually as common as they once thought in a lot of studies there was problems with the studies, they were flawed, and they're thinking it's not as common as they initially thought, doesn't mean you're not going to get a question presenting it this way. So be familiar. It can happen, but just not as commonly as they thought. The studies were pretty flawed, and they're kind of going back on some of what they've said about that. So anyways, on physical exam, there's two things for the esculptatory findings in a patient with MVP that you need to know.

So one is that they're going to have this mid to late systolic ejection click. That's huge. Don't forget that it's probably the most important thing to know about MVP, and it's from the snapping of the mitral chordae when the valve prolapses into the atrium.

So that's that mid to late systolic ejection clip. And then also be aware that these patients very well, very likely may also have mitral regurgitation murmur present, because remember the association between the two. Now, the other thing you need to remember, because I haven't gone over this in any of the other ones, because I didn't need to, because you know the rules, is that MVP, again, remember, it hates conforming to the rules. so mvp you're going to see the opposite increased preload like raising the legs more blood into the heart these patients are actually going to have a shortened length of murmur and causing the click to be delayed so it happens later and then decreased preload of course is going to cause the murmur duration to increase and the click will occur earlier so remember this is the only one i'm going over this because everything else remember increase venous return increase murmur Decreased venous return, decreased intensity of the murmur, except for MBP and hypertrophic cardiomyopathy.

So remember that. because that'll help you differentiate it from some of the other ones now as far as treatment asymptomatic you're just going to reassure these patients which will be most of them honestly most patients will not have a lot of symptoms with mvp mvp if they do have severe mitral regurgitation they may need surgery to repair the valve and then for some of the autonomic dysfunction symptoms you can use beta blockers to help with that all right so let's move on to the the right side of the heart I'm going to keep these pretty brief because there's not a lot to know compared to the left side of murmurs. And the fact of the matter is, is that they overlap with the left side of murmurs.

So if you already know aortic stenosis, then you pretty much know pulmonic stenosis, at least as far as the physical exam findings. So I'd say know the left side of murmurs really well, and then you'll know the right side of ones because they're similar. Just remember they increase with inspiration. And they're most of the time not tested on as frequently, but let's go over them real quick.

So pulmonic stenosis. It's going to be an outflow obstruction of the right ventricle due to a stenotic pulmonary valve. And the other thing too with either all of the pulmonary conditions, pulmonic stenosis, pulmonary regurg, is that these are very often congenital heart diseases.

They're very commonly seen in children. So this is what pulmonary valve stenosis will look like here. We can see it's just a stenotic valve instead of being kind of opened up here that's like nice and tight, and it's just stenotic.

It's just stenosis. That's pulmonary stenosis. It's seen in about 7% of children with congenital heart disease.

Like I said, it's very common in children. The pulmonic ones are, you know, more commonly seen in children. Now, etiologies, it can be an isolated lesion, but it's also commonly associated with Tetralogy of Fallot.

Congenital Rubella Syndrome is a big one, and Newnan Syndrome as well. Clinical manifestations, mostly asymptomatic most of the time, but it's possible to develop exertional dyspnea other symptoms of right-sided heart failure and then the physical exam well do you know what aortic stenosis sounds like you probably remember that's a systolic crescendo decrescendo so what do you think pulmonary pulmonic stenosis is gonna sound like systolic crescendo decrescendo only difference is it's gonna be best heard at the left upper sternal border the pulmonic area instead of the right upper sternal border like in aortic stenosis and then it can radiate to the neck just like an aortic stenosis but remember it's going to increase in intensity with inspiration so rinspiration and that's how you'll differentiate it from aortic stenosis in addition to the location so remember that treatment mild disease just observe these patients if they do have moderate to severe disease you can perform a balloon valvuloplasty or in some severe cases you have to have a surgical replacement of the the valve so pulmonary regurgitation this is going to be a valvular abnormality of the pulmonary valve It's going to lead to backflow from the pulmonary artery back into the right ventricle. So we can see that here.

You have the pulmonic valve that's going to lead to backflow back into the right ventricle here. So that is pulmonary regurg. And in severe cases, this can lead to right-sided heart failure. Etiologies can often be, and again, like I said, all the pulmonary ones are often congenital.

It can be seen alongside tetralogy of fallot, endocarditis, rheumatic heart disease. Clinical manifestations, again, generally they're going to be asymptomatic. Unless it's severe, then they can develop symptoms of right-sided heart failure.

But most of the time, these patients will be pretty much asymptomatic. Physical exam, just like its cousin aortic regurg, this is going to be a diastolic decrescendo murmur, but it's going to be heard at the left upper sternal border, the pulmonic area. And then remember, on all of these right-sided ones, increase in intensity with inspiration, rinspiration.

So that's the difference there. And then the other thing that you need to know for this, because I got stumped on a question with this, they may not call it pulmonary regurgitation. So you may have a question and you'll look at the vignette and you'll say, okay, I know this is pulmonary regurg.

You look at the answers and pulmonary regurg isn't there. And you're like, what? But what may be there is something known as a Graham steel murmur. So the murmur is also known as a Graham steel.

And this is how it's spelled. S-T-E-E-L-L. I didn't make a spelling error there. And that's what it's spelled.

Like in the way that I remember that now, back then, I think I may have forgotten it. I may have gotten it wrong. But remember, Graham Steele sounds like the Man of Steel, sounds like a superhero. And you can remember Graham Steele is protector of the realm. So Graham Steele, protector of the realm.

So remember, protector of the realm, PR stands for pulmonary regurgitation. Graham Steele, he's a superhero. He's protector of the realm, PR, pulmonary regurg.

So hopefully that'll help you. If you do get that question, you can remember that's pulmonary regurg. Now, as far as treatment observation, treat the underlying cause in a lot of cases.

So whether it's Tetralogy of flow, endocarditis, just treat the underlying cause most of the time. Otherwise, it's just observation if they're asymptomatic. Okay, so moving on to tricuspid stenosis. We are getting there.

We're almost done. Okay, so this is actually pretty rare, and it's usually found along with either tricuspid regurge or other valvular lesions. You're not going to find this one as an isolated lesion. It's basically just a stenotic tricuspid valve due to some underlying condition.

and it leads to blood backing up in the right atrium eventually leading to a right atrial dilation or enlargement and potentially if it's left untreated it can lead to right-sided heart failure so you can see that's what this looks like here you have this um this tricuspid valve that is nice and stenotic here nice and tight instead of being wide open like this just a little bit of blood is able to get through so you can potentially have blood backing up into this right atrium and you can see how it's dilated here compared to to this right atrium here because not as much is getting through So you have increased pressure there and some of the problems associated with that. Now, etiologies really should just focus on rheumatic heart disease. It's the most common cause of tricuspid stenosis.

There's also some iatrogenic causes like from radiation therapy, fibrosis from endocardial pacemaker leads, but really just focus on rheumatic heart disease. Don't waste your time with the less common things. Focus on the high yield stuff.

So clinical manifestations, again, like all of these, fatigue, dyspnea. Just remember this is normally not an isolated lesion so you're going to have symptoms from not only tricuspid stenosis but maybe mitral aortic valve disease. So overall the clinical manifestations are not too specific really like all of these so I just wouldn't focus on the clinical manifestations. Let's move on to physical exam. So the murmur of tricuspid stenosis is going to be a diastolic murmur.

It's best heard at the left lower sternal border which again is the tricuspid area. Then the other thing that you should remember just like its cousin mitral stenosis. It also has an opening snap So like I said, if you know the left side really well, you're gonna know the physical exam for the right side really well So just really remember your left side and then you'll always know the the right side because like I said, they're the same The only difference here is that the opening snap normally occurs a little later than what's heard in mitral stenosis And then again remember the only difference is going to be a RIN spiration.

It's going to increase with inspiration and then it's heard in the the tricuspid area treatment surgery is going to be definitive and then medications can be used to decrease right atrial overload like diuretics okay so tricuspid regurg this is going to be it and then we'll be done this is going to be the back flow of blood into the right atrium during systole and only severe cases cause any problems like right-sided heart failure most people aren't going to actually have any hemodynamic consequences from tricuspid regurg And unlike some of the other right-sided murmurs, if you take a look at that here, so you can see a normal tricuspid valve, and then you can see over here you have this tricuspid valve that's actually going to have this regurg here for the blood backing up into the atrium there. So this one's actually pretty common, and a small degree of tricuspid regurg is actually seen in about 70% of adults. Most patients will be asymptomatic, but it's pretty common in...

a lot of the population actually. So compared to some of the other ones which are pretty rare, this one's actually pretty common. As far as etiologies, Epstein's anomaly is the most common congenital heart disease that causes the condition.

It can also be seen in infective endocarditis, Marfan syndrome, as well as some iatrogenic causes like from pacemaker leads. And even when endomyocardial biopsy is performed, sometimes you can have tricuspid regurg. Clinical manifestations, most patients are going to be asymptomatic. Of course, don't waste your time on this. You know, in some of the severe cases, you may have those nonspecific symptoms of dyspnea, exercise intolerance, etc.

Okay, physical exam. Again, remember, just like your left-sided murmur, you can figure it out with the right. So remember, mitral regurgitation, mostly regular, mostly rigid.

So this is obviously going to be just like that. In tricuspid regurg, it'll be a hollow systolic murmur. But this one's going to be best heard at the tricuspid area. So that's the difference there.

and then of course remember where inspiration is going to increase with inspiration treatment surgical definitive diuretics for fluid overload okay so that's it for the murmurs for your nccp blueprint i know i went through it kind of quickly but a lot of it had overlap and i didn't want to waste your time with too much on on those things so let's do five quick questions and then we will wrap it up okay so one name all of the diastolic murmurs remember miss prarts died so that's going to be ms mitral stenosis pulmonary regurg aortic regurg and tricuspid stenosis. Those are your diastolics. If it's not in that sentence, Ms. Prarts died, you know it is a systolic murmur.

Describe the murmur of aortic stenosis. murmur of aortic stenosis is going to be systolic crescendo decrescendo up then down and then it's going to radiate to the carotids number three what is the most common cause of mitral regurgitation in the u.s most common cause of mitral regurg in the u.s is going to be mvp mitral valve prolapse describe quincy's pulse quincy's pulse remember quincy is seen in the pinky Capillary pulsation in the fingertips or nail beds seen in aortic regurg. Squinky is seen in the pinky.

What is the most common cause of mitral stenosis? Most common cause of mitral stenosis, you have to know this one, is going to be rheumatic heart disease. Okay, so that is it for murmurs. Thank you so much. I appreciate everything, every comment, every like.

It really means so much to me. If you haven't checked out the podcast, please do. Cram the Pants on Apple Podcasts, Spotify. pretty much anywhere you listen to your podcast that should be on there.

Please send me a message. Let me know how this is helping you. And as always, good luck on your pants, your pannery, your EORs, and good luck in PA school.

Transcript for:Key Insights on Heart Murmurs

Transcript for:
Key Insights on Heart Murmurs