Valvular Heart Disease: Clinical Findings & Diagnosis PDF

Valvular Heart Disease: Clinical Findings & Diagnosis Patricia Happel, DO, FACOFP Associate Professor, Department of Family Medicine [email protected] Session Objectives By the end of the session, students should be able to: 1. Understand the cardiac cycle and what causes the normal heart sound...

Valvular Heart Disease: Clinical Findings & Diagnosis Patricia Happel, DO, FACOFP Associate Professor, Department of Family Medicine [email protected] Session Objectives By the end of the session, students should be able to: 1. Understand the cardiac cycle and what causes the normal heart sounds. 2. Identify normal heart sounds and understand where to auscultate for them. 3. Distinguish between regurgitant and stenotic valvular lesions during systole and diastole. 4. Understand the clinical findings and patient presentations by integrating the pathophysiology of underlying diseases. 5. Recognize the appropriate steps of management for patients with valvular heart disease. Outline Normal heart Systolic murmurs Anatomy of the Types heart Clinical presentation Physiology of the Causes cardiac cycle Diastolic murmurs S1 and S2 Types Heart murmurs Clinical presentation Definitions Causes Pathophysiology Complications Characteristics  Pre-lecture Assessment Answers 1) Name the semilunar valves: Aortic and pulmonary 2) Name the atrioventricular valves: Mitral and tricuspid 3) What occurs in systole? Ventricles contract 4) What occurs in diastole? Ventricles relax 5) Which valves open during systole? Aortic and pulmonary 6) Which valves open during diastole? Mitral and tricuspid Source: Scholar Rx 7) Is a heart sound due to opening or closing of valves? Closing 8) What causes the S1 sound? Closing of the mitral and tricuspid valve 9) What causes the S2 sound? Closing of the aortic and pulmonic valve 10)Does regurgitation occur when the valve is supposed to be open or closed? Closed 11)Does stenosis occur when the valve is supposed to be open or closed? Open  Normal Cardiac Cycle Systole (LUB) Ventricles contract Aortic and pulmonic valves open Tricuspid and mitral valves close Diastole (DUB) Atria contract, ventricles fill Tricuspid and mitral valves open Aortic and pulmonic valves close Source: Scholar Rx Physiology of Cardiac Cycle Phases of the cardiac cycle are associated with pressure and volume changes in the chambers Source: Le T, Bhushan V. Cardiovascular. First Aid for the USMLE Step 1 2019, 29th ed. New York, NY: McGraw-Hill; 2018. Anatomy of the Heart Angle of Louis = Rib 2 Auscultation Aortic Area 2nd ICS at right sternal border Pulmonic Area 2nd ICS at left sternal border Tricuspid Area 4th ICS at left sternal border Mitral Area 5th ICS at midclavicular line Source: Bickley, LS, Szilagyi, PG. The Cardiovascular System. Hoffman RM, ed. Bates’ Guide to Physical Examination and History Taking, 12th ed. Philadelphia, PA: Wolters Kluwer; 2017.  Normal Heart Sounds S1 Occurs at beginning of systole Due to closure of atrioventricular valves Louder at apex S2 Occurs at the beginning of diastole Due to closure of semilunar valves Louder at base Source: Bickley, LS, Szilagyi, PG. The Cardiovascular System. Hoffman RM, ed. Bates’ Guide to Physical Examination and History Taking, 12th ed. Philadelphia, PA: Wolters Kluwer; 2017.  Physiologic splitting of S2 S2 physiologically splits with inspiration ↓intrathoracic pressure  ↑ venous return  ↑ blood volume in RV  pulmonic valve stays open longer A2 is heard before P2 Best heard in pulmonic area Splitting can be pathologic (wide, fixed, paradoxical) Source: Bickley, LS, Szilagyi, PG. The Cardiovascular System. Hoffman RM, ed. Bates’ Guide to Physical Examination and History Taking, 12th ed. Philadelphia, PA: Wolters Kluwer; 2017.  Pathological splitting of S2 Normally P2 closes slightly after A2 during inspiration Various pathological process can affect the timing or sequence of valve closure Source: Scholar Rx Heart murmurs Audible vibrations that are caused by increased turbulence of blood flow in the heart Caused by valvular disease: – Regurgitation: failure of a valve to close completely, thereby allowing backflow of blood – Stenosis: failure of a valve to open completely, obstructing forward flow Source: Mitchell RN, Connolly AJ. The Heart: Valvular Heart Disease. Kumar V, Abbas AK, Aster JC, eds. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Philadelphia, PA: Elsevier; 2021.  Characteristics of murmurs Timing: systolic or diastolic Shape: crescendo, decrescendo, plateau Location: 2nd, 4th or 5th ICS Radiation: eg, into axilla, carotids Intensity: Grade I-VI Quality: blowing, harsh, rumbling, musical Pitch: low, medium, high Source: Bickley, LS, Szilagyi, PG. The Cardiovascular System. Hoffman RM, ed. Bates’ Guide to Physical Examination and History Taking, 12th ed. Philadelphia, PA: Wolters Kluwer; 2017.  Characteristics of murmurs Intensity: Does not correlate with disease severity* Radiation: Grade Description Very faint, heard only after listener has Grade 1 “tuned in”; may not be heard in all positions Quiet, but heard immediately after Grade 2 placing the stethoscope on the chest Grade 3 Moderately loud Grade 4 Loud, with palpable thrill Very loud, with thrill. May be heard Grade 5 when the stethoscope is partly off the chest Very loud, with thrill. May be heard Grade 6 with stethoscope entirely off the chest Source: Bickley, LS, Szilagyi, PG. The Cardiovascular System. Hoffman RM, ed. Bates’ Guide to Physical Examination and History Taking, 12th ed. Philadelphia, PA: Wolters Kluwer; 2017. Location of murmurs Le T, Bhushan V. Cardiovascular. First Aid for the USMLE Step 1 2019, 29th ed. New York, NY: McGraw-Hill; 2018 Dynamic Auscultation Respiration Valsalva/Standing Rapid Squatting/Leg Raise Hand grip Source: O’Gara PT, Loscalzo, J. Approach to a Patient with a Heart Murmur. Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine, 20th ed. New York, NY: McGraw-Hill; 2018.  Dynamic Auscultation Respiration – Inspiration ↑ RV preload – ↑ intensity of R-sided murmurs ↓ LV preload – ↓ intensity of L-sided murmurs – Expiration usually ↑ L-sided murmurs Source: Gersh, BJ. Physiologic and pharmacologic maneuvers in the differential diagnosis of heart murmurs and sounds. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on September 2, 2021.)  Dynamic Auscultation Valsalva/standing – ↓ LV preload, ↓ LV afterload, ↓ RV preload Improves most murmurs except… HOCM Worsens MVP (mitral valve prolapse) and HOCM (hypertrophic obstructive cardiomyopathy) Source: Gersh, BJ. Physiologic and pharmacologic maneuvers in the differential diagnosis of heart murmurs and sounds. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on September 2, 2021.)  Dynamic Auscultation Rapid squatting/leg raise – ↑ LV preload, ↑ RV preload, no effect on afterload – Worsens most murmurs except… – Improves MVP and HOCM Source: Gersh, BJ. Physiologic and pharmacologic maneuvers in the differential diagnosis of heart murmurs and sounds. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on September 2, 2021.)  Dynamic Auscultation Hand grip – ↑ LV afterload – Affects L-sided murmurs only Worsens mitral/aortic regurgitation Improves aortic stenosis, worsens mitral stenosis Source: Gersh, BJ. Physiologic and pharmacologic maneuvers in the differential diagnosis of heart murmurs and sounds. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on September 2, 2021.) Systolic & Diastolic Murmurs Almost always pathologic – must be worked up Systolic Murmurs Diastolic Murmurs Aortic Stenosis Aortic Regurgitation Pulmonic Stenosis Pulmonic Regurgitation Mitral Regurgitation Mitral Stenosis Tricuspid Regurgitation Tricuspid Stenosis Mitral Valve Prolapse Source: Bickley, LS, Szilagyi, PG. The Cardiovascular System. Hoffman RM, ed. Bates’ Guide to Physical Examination and History Taking, 12th ed. Philadelphia, PA: Wolters Kluwer; 2017. Systolic Murmurs  Aortic Stenosis Clinical presentation: Crescendo-decrescendo systolic murmur best heard at the right 2nd ICS near the sternal border that radiates to the carotids ↑ intensity with ↑ preload ↓ intensity with ↑ afterload or ↓ preload Severe cases can develop paradoxical splitting of S2 Syncope, angina, and dyspnea on exertion (“SAD”) Paradoxical splitting “Pulsus parvus et tardus” Source: Bickley, LS, Szilagyi, PG. The Cardiovascular System. Hoffman RM, ed. Bates’ Guide to Physical Examination and History Taking, 12th ed. Philadelphia, PA: Wolters Kluwer; 2017. O’Gara PT, Loscalzo, J. Approach to a Patient with a Heart Murmur. Jameson J, Fauci AS, Kasper DL, Hauser SL, Le T, Bhushan V. Cardiovascular. First Aid for the USMLE Step 1 2019, 29th ed. New York, NY: McGraw-Hill; 2018.  Aortic Stenosis Causes: Calcified valve – Age-related degeneration in older Spectrum of Calcific Aortic Valve Disease. Circulation, 2005 patients – Congenital bicuspid aortic valve in younger patients TAVR Shows Favorable Safety in Patients with Bicuspid Source: Le T, Bhushan V. Cardiovascular. First Aid for the USMLE Step 1 2019, 29th ed. New York, NY: McGraw-Hill; 2018. Valve. DAIC, 2020. Mitchell RN, Connolly AJ. The Heart: Valvular Heart Disease. Kumar V, Abbas AK, Aster JC, eds. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Philadelphia, PA: Elsevier; 2021. Source: Mitchell RN, Connolly AJ. The Heart: Valvular Heart Disease. Kumar V, Abbas AK, Aster JC, eds. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Philadelphia, PA: Elsevier; 2021. Lerman DA, Prasad S, Alotti N. Calcific Aortic Valve Disease: Molecular Mechanisms and Therapeutic Approaches. Eur Cardiol. 2015;10(2):108-112. doi:10.15420/ecr.2015.10.2.108  Pulmonic Stenosis Clinical presentation: Crescendo-decrescendo systolic murmur best heard at the left 2nd ICS near the sternal border that radiates to the left shoulder and neck ↑ intensity with inspiration Can develop wide splitting of S2 Congenital (tetralogy of Fallot & congenital rubella) Source: Bickley, LS, Szilagyi, PG. The Cardiovascular System. Hoffman RM, ed. Bates’ Guide to Physical Examination and History Taking, 12th ed. Philadelphia, PA: Wolters Kluwer; 2017. O’Gara PT, Loscalzo, J. Approach to a Patient with a Heart Murmur. Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine, 20th ed. New York, NY: McGraw-Hill; 2018.  Mitral Regurgitation Clinical presentation: Blowing holosystolic murmur best heard at the apex that radiates to the left axilla ↑ intensity with ↑afterload and ↑ preload ↓ intensity with ↓ preload Source: Bickley, LS, Szilagyi, PG. The Cardiovascular System. Hoffman RM, ed. Bates’ Guide to Physical Examination and History Taking, 12th ed. Philadelphia, PA: Wolters Kluwer; 2017. O’Gara PT, Loscalzo, J. Approach to a Patient with a Heart Murmur. Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine, 20th ed. New York, NY: McGraw-Hill; 2018 Le T, Bhushan V. Cardiovascular. First Aid for the USMLE Step 1 2019, 29th ed. New York, NY: McGraw-Hill; 2018. Mitral Regurgitation Causes: Mitral Valve Prolapse Rheumatic heart disease (early) Infective endocarditis Post-myocardial infarction – Acute papillary muscle rupture PubMed PMID: 26270068 LV dilation secondary to heart failure Source: Bickley, LS, Szilagyi, PG. The Cardiovascular System. Hoffman RM, ed. Bates’ Guide to Physical Examination and History Taking, 12th ed. Philadelphia, PA: Wolters Kluwer; 2017. O’Gara PT, Loscalzo, J. Approach to a Patient with a Heart Murmur. Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine, 20th ed. New York, NY: McGraw-Hill; 2018.  Mitral Valve Prolapse Pathophysiology: weakening of valve leaflets and chordae tendinae  ballooning of valve leaflets into left atrium during systole Clinical presentation: Late systolic crescendo murmur with midsystolic click (MC) best heard at the apex – MC caused by sudden tension on chordae tendineae – Crescendo = regurgitant murmur ↑ intensity and delayed MC with ↓ preload ↓ intensity and earlier MC with ↑ preload Source: Bickley, LS, Szilagyi, PG. The Cardiovascular System. Hoffman RM, ed. Bates’ Guide to Physical Examination and History Taking, 12th ed. Philadelphia, PA: Wolters Kluwer; 2017. O’Gara PT, Loscalzo, J. Approach to a Patient with a Heart Murmur. Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine, 20th ed. New York, NY: McGraw-Hill; 2018. Le T, Bhushan V. Cardiovascular. First Aid for the USMLE Step 1 2019, 29th ed. New York, NY: McGraw-Hill; 2018.  Mitral Valve Prolapse Causes: Myxomatous degeneration – Increased deposition of mucopolysaccharides in the spongiosa layer of the valve – Connective tissue disorders Marfan syndrome: AD defective in fibrillin which crosslinks elastin Can lead to mitral regurgitation Source: Mitchell RN, Connolly AJ. The Heart: Valvular Heart Disease. Kumar V, Abbas AK, Aster JC, eds. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Philadelphia, PA: Elsevier; 2021. Pislaru S, Enriquez-Sarano M (2017). Definition and Diagnosis of Mitral Valve Prolapse. Otto CM, ed. UpToDate. Accessed September 13, 2020.  Tricuspid Regurgitation Clinical presentation: Blowing holosystolic murmur best heard at the left lower sternal border ↑ intensity with inspiration Source: Bickley, LS, Szilagyi, PG. The Cardiovascular System. Hoffman RM, ed. Bates’ Guide to Physical Examination and History Taking, 12th ed. Philadelphia, PA: Wolters Kluwer; 2017. O’Gara PT, Loscalzo, J. Approach to a Patient with a Heart Murmur. Jameson J, Fauci AS, Kasper Le T, Bhushan V. Cardiovascular. First Aid for the USMLE Step 1 2019, 29th ed. New York, NY: McGraw-Hill; 2018. Tricuspid Regurgitation Causes: Pulmonary hypertension Ebstein’s anomaly – Downward displacement of the tricuspid valve into the RV – “atrialization of the RV” – Lithium exposure in utero Infective endocarditis – IV drug user (don’t “tri” drugs) Acute, caused by Staph aureus Source: Bickley, LS, Szilagyi, PG. The Cardiovascular System. Hoffman RM, ed. Bates’ Guide to Physical Examination and History Taking, 12th ed. Philadelphia, PA: Wolters Kluwer; 2017. O’Gara PT, Loscalzo, J. Approach to a Patient with a Heart Murmur. Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo Diastolic Murmurs  Aortic Regurgitation Clinical presentation: Blowing early decrescendo diastolic murmur best heard at the left midsternal border that radiates to the apex ↑ intensity with ↑ afterload and ↑ preload ↓ intensity with ↓ preload Widened pulse pressure, head bobbing, bounding pulse (water hammer pulse) Hyperdynamic circulatory state Source: Bickley, LS, Szilagyi, PG. The Cardiovascular System. Hoffman RM, ed. Bates’ Guide to Physical Examination and History Taking, 12th ed. Philadelphia, PA: Wolters Kluwer; 2017. DL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine, 20th ed. New York, NY: McGraw-Hill; 2018. Le T, Bhushan V. Cardiovascular. First Aid for the USMLE Step 1 2019, 29th ed. New York, NY: McGraw-Hill; 2018. Aortic Regurgitation Causes: Congenital bicuspid aortic valve Endocarditis Aortic root dilation – Aneurysm = dilation of vessel greater than 50% normal Hypertension Connective tissue diseases Source: Bickley, LS, Szilagyi, PG. The Cardiovascular System. Hoffman RM, ed. Bates’ Guide to Physical Examination and History Taking, 12th ed. Philadelphia, PA: Wolters Kluwer; 2017. O’Gara PT, Loscalzo, J. Approach to a Patient with a Heart Murmur. Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine, 20th ed. New York, NY: McGraw-Hill; 2018..  Pulmonic Regurgitation Clinical presentation: Blowing early decrescendo diastolic murmur best heard at the 2nd ICS at the left sternal border that radiates along the left sternal border ↑ intensity with inspiration Caused by pulmonary hypertension Source: O’Gara PT, Loscalzo, J. Approach to a Patient with a Heart Murmur. Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine, 20th ed. New York, NY: McGraw-Hill; 2018. Le T, Bhushan V. Cardiovascular. First Aid for the USMLE Step 1 2019, 29th ed. New York, NY: McGraw-Hill; 2018.  Mitral Stenosis Clinical presentation: Non-radiating decrescendo diastolic murmur following an opening snap (OS) best heard at the apex – OS caused by abrupt halt of stiffened leaflets ↑ intensity with expiration, left lateral decubitus ↓ intensity with ↓ preload Can cause LA dilation  atrial fibrillation and dysphagia Source: Bickley, LS, Szilagyi, PG. The Cardiovascular System. Hoffman RM, ed. Bates’ Guide to Physical Examination and History Taking, 12th ed. Philadelphia, PA: Wolters Kluwer; 2017. O’Gara PT, Loscalzo, J. Approach to a Patient with a Heart Murmur. Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo Le T, Bhushan V. Cardiovascular. First Aid for the USMLE Step 1 2019, 29th ed. New York, NY: McGraw-Hill; 2018.  Mitral Stenosis Causes: Chronic rheumatic heart disease – Sequela following pharyngeal infection with Group A Streptococci – Host immune response against streptococcal M protein can also recognize cardiac self antigens – Leaflet thickening, commissural fusion and shortening, and thickening and fusion of the chordae tendineae – Can involve mitral, aortic or tricuspid valve Source: Mitchell RN, Connolly AJ. The Heart: Valvular Heart Disease. Kumar V, Abbas AK, Aster JC, eds. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Philadelphia, PA: Elsevier; 2021.  Tricuspid Stenosis Clinical presentation: Non-radiating decrescendo diastolic murmur following an opening snap (OS) best heard at the lower left sternal border ↑ intensity with inspiration Rare Source: O’Gara PT, Loscalzo, J. Approach to a Patient with a Heart Murmur. Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine, 20th ed. New York, NY: McGraw-Hill; 2018. Le T, Bhushan V. Cardiovascular. First Aid for the USMLE Step 1 2019, 29th ed. New York, NY: McGraw-Hill; 2018. Complications Stenosis: ↑ pressure in chamber before the diseased valve  backflow of blood and hypertrophy Regurgitation: ↑ blood volume in chamber before diseased valve  backflow of blood and dilation – Untreated will lead to heart failure (HF) Left-sided HF: pulmonary congestion and edema  cough and dyspnea, orthopnea, paroxysmal nocturnal dyspnea Right-sided HF: engorgement of systemic and portal venous systems  hepatomegaly, JVD, peripheral edema Source: Mitchell RN, Connolly AJ. The Heart: Valvular Heart Disease. Kumar V, Abbas AK, Aster JC, eds. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Philadelphia, PA: Elsevier; 2021.  Management Transthoracic echocardiography (TTE) is the gold standard Asymptomatic – TTE for initial visit and every 1-5 years depending on severity Symptomatic – Stable: TTE every 1-5 years TTE is warranted among patients with known VHD with change in clinical status or cardiac examination Surgery is indicated based on size of valve opening, regurgitant volume/fraction, aortic velocity, overall cardiac function Source: Doherty JU, et al. Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Cardiol. 2017;70(13):1647-1672. doi:10.1016/j.jacc.2017.07.732  Summary Heart murmur is pathognomonic for valvular heart disease See following tables summarizing clinical presentation, auscultatory findings, and underlying causes Complications: – Stenosis  increased chamber pressure – Regurgitation  increased volume in chamber – Untreated will lead to heart failure Evaluation: – TTE is gold standard – initial evaluation for new cardiac murmur, change in clinical status or cardiac exam  Question A 72-year-old male presents to the ED for chest pain. It began after mowing the lawn and was relieved once he stopped. During that episode, he felt short of breath and shortly after, he fainted. No head trauma was stated. He has a past medical history of hypertension that is well controlled with lisinopril. Upon cardiac auscultation, a crescendo-decrescendo murmur is heard at the 2nd right intercostal space that gets louder with rapid squatting. He also has delayed 1+ pulses in all 4 extremities. 1) What murmur is this patient presenting with? 2) What is the pathophysiology? 3) Where does this murmur tend to radiate?  Question A 72-year-old male presents to the ED for chest pain. It began after mowing the lawn and was relieved once he stopped. During that episode, he felt short of breath and shortly after, he fainted. No head trauma was stated. He has a past medical history of hypertension that is well controlled with lisinopril. Upon cardiac auscultation, a crescendo-decrescendo murmur is heard at the 2nd right intercostal space that gets louder with rapid squatting. He also has delayed 1+ pulses in all 4 extremities. What murmur is this patient presenting with? 1) What murmur is this patient presenting with? Aortic stenosis 2) What is the pathophysiology? Age-related calcification 3) Where does this murmur tend to radiate? Carotids  Question A 42-year-old Hispanic woman presents to the ED for a recent onset of chest palpitations which she described as her heart beating out of her chest. It is triggered by exercise and stress. She is a “healthy” individual who does not take any medications, but states has recently found it harder to swallow certain foods. Upon further questioning, she remembered getting strep throat frequently as a child but never received medical care. A murmur is heard on cardiac auscultation that worsens with passive leg raising. What else is most likely heard on auscultation? A. Holosystolic murmur best heard at the apex B. Crescendo-decrescendo murmur best heard at the right 2nd ICS C. Decrescendo diastolic murmur following an opening snap best heard at apex D. Late systolic murmur with midsystolic click best heard at the apex E. Continuous machine-like murmur  Question A 42-year-old Hispanic woman presents to the ED for a recent onset of chest palpitations which she described as her heart beating out of her chest. It is triggered by exercise and stress. She is a “healthy” individual who does not take any medications, but states has recently found it harder to swallow certain foods. Upon further questioning, she remembered getting strep throat frequently as a child but never received medical care. A murmur is heard on cardiac auscultation that worsens with passive leg raising. What else is most likely heard on auscultation? A. Holosystolic murmur best heard at the apex B. Crescendo-decrescendo murmur best heard at the right 2nd ICS C. Decrescendo diastolic murmur following an opening snap best heard at apex D. Late systolic murmur with midsystolic click best heard at the apex E. Continuous machine-like murmur Rules to Remember Inspiration worsens R-sided murmurs Hand grip worsens L-sided regurgitations Rapid squatting and leg raise ↑ preload Standing and Valsalva ↓ preload Maneuvers that ↓ preload improve most murmurs Maneuvers that ↑ preload worsen most murmurs Exceptions: MVP and HOCM  Systolic Murmur Auscultation* Other clinical findings Cause Aortic Stenosis S: crescendo-decrescendo ↑ intensity with squatting, leaning forward, Calcified valve: age-related L/R: R 2nd ICS near sternal border, radiates expiration degeneration or congenital bicuspid to carotids Reversed splitting of S2 aortic valve Q: harsh Syncope, angina, and dyspnea on exertion I: loud Pulsus parvus et tardus P: medium Pulmonic Stenosis S: crescendo-decrescendo ↑ intensity with inspiration Congenital L/R: L 2nd ICS near sternal border, radiates to Pathological splitting of S2 L shoulder and neck Q: harsh I: soft to loud P: medium Mitral Regurgitation S: holosystolic ↑ intensity with handgrip and expiration Mitral valve prolapse L/R: apex, radiates to L axilla Papillary muscle rupture (post-MI) Q: blowing LV dilation I: soft to loud P: high Mitral Valve Prolapse S: Late crescendo, preceded by midsystolic ↑ intensity and delayed MC with squatting Myxomatous degeneration click Typically asymptomatic L: apex Can lead to MR Tricuspid Regurgitation S: holosystolic ↑ intensity with inspiration Ebstein anomaly L/R: L lower sternal border, radiates to R of Associated with increased pressure in Infective endocarditis in IV dug user the sternum pulmonary arteries Q: blowing I: variable P: medium *S – Shape, L/R – location/radiation, Q – quality, I – intensity, P - pitch  Diastolic Murmur Auscultation* Other clinical findings Cause Aortic Regurgitation S: early decrescendo ↑ intensity with handgrip, leaning Congenital bicuspid aortic valve L/R: L midsternal border, radiates to the forward, expiration Aortic root dilation apex Widened pulse pressure Q: blowing Head bobbing I: soft to loud Bounding pulse P: high Pulmonic S: early decrescendo ↑ intensity with inspiration Pulmonary hypertension Regurgitation L/R: L 2nd ICS near sternal border, radiates along L sternal border Q: blowing I: soft P: high Mitral Stenosis S: Decrescendo following opening snap ↑ intensity with expiration, left lateral Chronic rheumatic heart disease L/R: apex, non-radiating decubitus Q: rumbling I: soft to loud P: low Tricuspid Stenosis S: Decrescendo following opening snap ↑ intensity with inspiration L/R: L lower sternal border, non- Rare radiating Q: rumbling I: soft P: low *S – Shape, L/R – location/radiation, Q – quality, I – intensity, P - pitch Heart Sounds: https://open.umich.edu/find/open-educational-resources/medical/heart-sound- murmur-library https://www.uptodate.com/contents/auscultation-of-heart-sounds https://www.easyauscultation.com/auscultation-repetition-training https://depts.washington.edu/physdx/heart/tech.html THANK YOU!  Lecture Feedback Form https://comresearchdata.nyit.edu/redcap/surveys/?s=HRCY448FWYXREL4R