Systolic Murmur- occur during ventricular systole, heard between 1st and 2nd heart sound
Type of valve
defect
Mitral
regurgitation
Murmur characteristic
Best heard during
inspiration/ expiration
Expiration
Pan-systolic murmur,
Best heard at apex,
Radiate to left axilla
*can radiate to neck
posterior leaflet involved
Other clinical signs
o
o
o
o
if
Irregularly irregular
pulse (AF)
Displaced apex beat
Thrusting apex beat
Soft/ absent S1
Indicators of severity
o
o
o
o
Tricuspid
regurgitation
Pan-systolic murmur,
Maximal over left lower
sternal edge
Inspiration
o
o
o
o
o
Aortic stenosis
Ejection systolic murmur,
Harsh,
crescendodecrescendo
Maximal over right sternal
edge,
Radiate to carotids (neck)
Expiration
o
o
o
o
o
o
Giant V wave on
raised JVP
Right parasternal
heave
Pulsatile liver
Ascites
Peripheral edema
-
Slow rising pulse
Low volume pulse
Heaving apex beat
Soft S2
BP narrow pulse
pressure
o
o
o
o
o
o
o
Enlarged left ventricle (displaced/
thrusting apex beat)
Presence of S3 (rapid filling LV by
large volume of blood stored in LA
in diastole)
Presence
of
pulmonary
hypertension (loud P2, raised JVP,
parasternal
heave,
tender
hepatomegaly)
Functional TR and PR
Narrow pulse pressure
Soft S2
Narrow/ reverse split-second heart
sound
Systolic thrill and heaving apex
beat
S4
Anacrotic pulse= a variant of
pulsus parvus et tardus in which a
notch is palpable on upstroke of
pulse wave
Long and peaking ESM
Causes
1.
2.
Rheumatic heart disease
Papillary muscle/ chordae
tendinea rupture (posterior or
inferior MI)
3. Infective endocarditis
4. Left ventricular hypertrophy/
dilatation
5. Mitral valve prolapsed
6. Connective tissue disorder
(Marfan/ Ehler Danlos)
7. Valvotomy/ valvuloplasty
Primary:
a. Rheumatic heart disease
b. IE (IVDU)
c. Congenital Ebstein anomaly
d. Carcinoid heart disease
Secondary:
a. Cardiomegaly
producing
functional TR (cor pulmonale
2° to lung ds/ mitral valve
disease)
b. Cardiomyopathy + MR
c. AMI with papillary muscle
infarct
AS triad: syncope, angina, SOB
Causes:
1. Rheumatic heart disease
2. IE
3. Degenerative calcification
4. Calcification of congenital
bicuspid valve
*** DDX: HOCM
o Young adults
o Jerky pulse
o Prominent ‘a’ wave in JVP
o Double impulse at apex
o Palpable S4
Systolic Murmur- occur during ventricular systole, heard between 1st and 2nd heart sound
o
o
Ventricular
septal defect
Pulmonary
stenosis
Pan-systolic murmur
Over all precordium
Maximal heard over left
sternal edge (lower/
upper)
Ejection-systolic murmur at
left upper sternal edge
May radiate to back
No changes
Inspiration
Mild: displaced apex beat (LVH)
Moderate: palpable thrill
Severe: parasternal heave (RVH)
o
o
o
Soft P2
Normal S2
Wide splitting of S2
(ASD)
Others: Functional murmur due to change in rate of blood flow/ hyperdynamic circulation:
a. Fever
b. Anaemia
c. Exercise
d. Hyperthyroidism
Systolic thrill at left lower
sternal edge
Family history of sudden
death at young age
Systolic Murmur- occur during ventricular systole, heard between 1st and 2nd heart sound
Systolic Murmur- occur during ventricular systole, heard between 1st and 2nd heart sound
Diastolic Murmur- occur during cardiac diastole, heard after 2nd heart sound
Type of valve
defect
Mitral stenosis
Aortic
regurgitation
Characteristic of murmur
Mid-diastolic murmur,
Low pitched
Best heard left lateral
position
Early diastolic murmur,
High pitched
Maximal at left upper
sternal edge
Best heard leaning forward
Inspiration/
Expiration
Expiration
o
o
Expiration
o
o
o
o
Other clinical signs
Indicators of severity
Loud S1 (occurs when leaftlets are
mobile, slammed shut during
ventricular systole)
Opening snap (d/t opening of
stenosed mitral valve pliable
leaftlets)
o
Collapsing pulse (waterhammer
pulse)
Corrigan’s sign- visible carotid
pulsation due to wide pulse
pressure
Quincke sign- nail bed capillary
pulsation
Displaced apex beat + thrusting
o
o
o
o
o
Others:
o De Musset’s sign- rhythmic
bobbing of head in synchrony with
heartbeat
o Mueller’s sign: uvular pulsation in
time with HR
o Duroziez’s sign- to and fro murmur
when femoral artery compressed
by stethoscope
o Traube’s sign- systolic pistol-shots
over femoral artery
o Hill’s sign (SBP in LL> UL)
o
o
o
o
o
Narrow distance between
opening snap and S2
Longer MDM
Pulmonary HPT
Right-sided heart failure
Wide pulse pressure
Signs of LVF
Displaced apex beat
Long EDM
Austin Flint murmur (MDM
with no opening snap)
Presence of S3
Hill’s sign
Causes
Congenital: congenital
parachute valve
Acquired:
- Rheumatic heart
disease
- Calcification of mitral
annulus & leaflets
- CTD (RA, SLE)
- Malignant carcinoid
Intrinsic valvular disease:
- Congenital bicuspid
valve
- IE
- Rheumatic heart
disease
- RA
Aortic root disease:
- Calcific AS
- Aortic dissection
- Syphilis
- Seronegative
spondyloarthropathy
- Marfan syndrome
Position: 45°, expose chest and neck
General:
- Body built
- Sign of respiratory distress
- Syndromic facies
Hands:
- Finger clubbing
- Stigmata of IE: splinter haemorrhage,
Osler’s node, Janeway lesion
- Peripheral cyanosis
- Radial scar*
- Arterial pulse:
a. Rate
b. Rhythm
c. Volume
d. Character
e. Any radio-radial delay
f. Collapsing pulse
Face:
Eye: pallor, jaundice
Mouth: oral hygiene, high-arched palate,
dental caries, central cyanosis
Neck: JVP
Chest
Inspection:
- Any midline sternotomy scar
- Visible heartbeat
Palpation:
- Apex beat + characteristic
- Palpable thrill
- Parasternal heave
Auscultation: listen for murmur + manouever
Description of murmur
1. Timing- Systolic/ diastolic
2. Character/ pitch
3. Maximally heard at which site
4. Any radiation
5. Intensity (grading)
6. Effects of posture + respiration
Continue with
1. Listen to lung bases for basal
crepitations
2. Peripheral edema- sacral+ leg
Complete with
- Abdominal examination:
Palpate liver- enlargement, tenderness,
pulsation
Palpate spleen- if suspect IE
- Measure blood pressure
- Presence and equality of peripheral
pulses