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Benign Vs Pathologic murmurs
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Benign
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Pathologic
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Hx
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• Normal appetite, energy, activities and growth
• No important Family Hx
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• Diaphoresisi and fatigue with feeding or workout, poor weight gain, chest pain, dizziness, syncope, shortness of breath
• Family Hx of sudden cardiac death, heart defects, etc
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Feature
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• Early or mid-systolic
• Grade I or II intensity that decrease on standing and Valsalva maneuver
• Low pitched, musical, pure, or squeeky tone at LLSB (still’s murmur) or high pitched at LUSB (Pulmonary flow murmur)
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• Harsh, holosystolic, diastolic
• Grade III intensity or higher
• ⤴️ with standing and Valsalva maneuver
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Other findings
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• None
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• Loud, fixed split, or single S2
• ⤵️ or absent femoral pulses
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Workup
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• None indicated
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• ECG (to assess for hypertrophy)
• Echocardiogram (to assess for structural abnormalities)
• Cardiology Referral
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Murmur
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Location
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Leg Raise
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Valsalva
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Tx
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Path
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Presentation
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Def Tx
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Mitral Stenosis
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diastolic w/ openin snap
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Apex
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Get worse
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Improves
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Preload Reduction
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Rheumatic Fever
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Afib, CHF
SOB
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Replace
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Aortic Stenosis
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Systolic / Crescendo-decrescendo
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Aortic w/ radiation to Carotids
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Get worse
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Improves
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Preload Reduction
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Calcification Bicuspid
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Angina, CHF
Syncope
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Replace
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Mitral Regurg
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Systolic
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Apex to Axilla
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Get worse
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Improves
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Preload Reduction
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Infxn Infarction
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CHF
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Replace
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Aortic Regurg
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Diastolic
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Aortic
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Get worse
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Improves
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Preload Reduction
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Infxn Infarction
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CHF
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Replace
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HCOM
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Systolic
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Apex
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Improves
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Get worse
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Increase Preload
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Congenital
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SOB, Sudden Death
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Replace
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Mitral Valve Prolapse
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Systolic
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Apex
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Improves
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Get worse
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Increase Preload
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Congenital
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CHF
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Replace
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Venous Return / Preload
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Afterload
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Drugs
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||||
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Increase
(leg raise/ squat)
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Decrease
(Valsalva/standing)
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Increase
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Decrease
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Diuretics
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ACEIs
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(Handgrip)
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(amyl Nitrate)
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|||||
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MS, AS
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⤴️
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⤵️
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⤵️(AS)
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⤴️(AS)
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Yes, but better
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Negligible Effect in (MS)
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AS (Replace)
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⊖
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||||
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MR, AR
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⤴️
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⤵️
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⤴️
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⤵️
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⊕
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VSD
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⤴️
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⤵️
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⤴️
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⤵️
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⊕
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⊕
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HOCM
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⤵️
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⤴️
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⤵️
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⤴️
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⊖
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⊖
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MVP
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⤵️
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⤴️
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⤵️
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⤴️
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⊖
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⊖
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Auscultation findings:
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Innocent murmur
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· 3-7 yo ped
· systolic, grade 2, never diastolic
· can happen when ⤴️ CO (fever)
· best heard @ Left Lower sternal border
· reassure
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Pulmonary flow murmur
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· also innocent murmur
· heart at 2nd left intercostal
· while pt laying down
· high-pitch, early systolic
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Venous hum
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· why?
· heard in neck / anterior chest
· disappear w/ compression of jugular v
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Machinary murmur
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· PDA
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ASD
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· Ejection murmur
· Wide fixed spilitting of P2
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Prosthetic Valve Dysfunction
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?
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• Transvalvular regurgitation (cusp degeneration)
• Paravalvular leak (annular degeneration, IE)
• Obstruction/stenosis of the valve (valve thrombus)
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Clx
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• New murmur (regurgitant or stenotic)
• Macroangiopathic hemolytic anemia
• HF symptoms, thromboembolism
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Dx
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• Echocardiography
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Chronic AR
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?
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• Congenital bicuspid aortic valve
• Post inflammatory (rheumatic heart disease, endocarditis)
• Aortic root dilation (Marfan syndrome, syphilis)
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Path
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• LV compensates w/ eccentric hypertrophy à ⤴️ SV & CO
• Eventual LV dysfunction à ⤵️ SV & COà HF
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Clx
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• Diastolic decrescendo murmur (best heard w/ pt sitting up, leaning forward, full expiration + at 3rd-4th left intercostal space)
• Widened pulse pressure (⤴️ SBP & ⤵️ DBP)
• Rapid rise-rapid fall (“water-hammer”) pulsation
• Abrupt carotid distension & collapse, “pistol-shot” femoral pulses
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MS
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🔉
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· Holosystolic murmur
· Apex
· S3
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S/S
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· SOB
· pHTN
· Eccentric LV hypertrophy
· ⤴️ LA pressure → HF
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Dx
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TTE
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Fast HY Review 