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Cardiac murmurs – diasystolic

Aortic regurgitation

Aortic regurgitation murmur

Aortic regurgitation results in regurgitation of blood from the aorta back into the left ventricle during diastole. This results in increased left ventricular end-diastolic volume.

  • Character: Early diastolic (sounds like a breath)
  • Best heard: upper right sternal edge (or lower left sternal edge sitting forwards); loudest on expiration
  • Radiation: none
  • Symptoms:
    • Fatigue
    • SOB
    • Palpitations
  • Signs:
    • Collapsing pulse
    • Wide pulse pressure
    • Very displaced thrusting apex (volume-loaded)
    • Backflow signs:
      • Corrigan’s (visible carotid pulsation)
      • de Musset’s (head-nodding pulse)
      • Quincke’s (red-coloured pulsation in nails)
    • ±Austin Flint murmur (apical diastolic rumble)

Causes of… Aortic regurgitation

Acute causes

  • Infective endocarditis
  • Aortic dissection

Chronic causes

  • Aortic root dilatation

    • Longstanding hypertension
    • Syphilitic aortitis

    • Aortic vasculitis (giant cell arteritis, Takayasu arteritis)

  • Connective tissue disorders (e.g. Marfan syndrome, ankylosing spondylitis, Ehlers–Danlos syndrome) – may also cause aortic root dilatation
  • Rheumatic heart disease
  • Congenital/bicuspid aortic valve

Mitral stenosis

Mitral stenosis murmur

Mitral stenosis causes increased resistance between left atrium and left ventricle. This results in high left atrial pressure and subsequent pulmonary hypertension.

  • Character: low rumbling mid-diastolic with opening snap
  • Best heard: apex in left lateral position; loudest on expiration using bell of stethoscope
  • Radiation: none
  • Symptoms:
    • Dyspnoea
    • Fatigue
    • Haemoptysis
    • Chest pain
  • Signs:
    • Malar flush (due to low cardiac output)
    • AF
    • Tapping apex (palpable S1)
    • Loud S1
    • Signs of pulmonary hypertension (RV heave, loud P2)

Causes of… Mitral stenosis

  • Rheumatic heart disease
  • Others causes rare (e.g. congenital, carcinoid)

Why don’t you test your knowledge?

What are the causes of a wide and narrow pulse pressure?

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What is an Austin Flint murmur?

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What are the Duke criteria for infective endocarditis?

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Try some OSCE stations!

  1. Cardiovascular examination
  2. Cardiovascular examination pansystolic murmur
  3. Cardiovascular examination valve replacement
  4. Aortic Stenosis
  5. Chest Pain 1
  6. And there’s lots more here!

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