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Cardiac murmurs – systolic

Aortic stenosis

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Aortic stenosis murmur

Aortic stenosis causes increased resistance between the left ventricle and systemic circulation. This results in limited cardiac output and subsequent LV hypertrophy.

  • Character: ejection systolic
  • Best heard: upper right sternal edge; loudest on expiration
  • Radiation: carotids and apex
  • Symptoms:
    • Exertional dyspnoea
    • Syncope
    • Angina (coronary perfusion impaired)
  • Signs:
    • Slow-rising pulse
    • Narrow pulse pressure
    • Heaving apex beat (pressure-loaded)
    • Soft or absent S2 (depending on AS severity)
    • May be signs of LVF (S3, pulmonary oedema)

Causes of… Aortic stenosis

  • Age (senile calcification; most)
  • Bicuspid aortic valve (e.g. Turner’s syndrome)
  • Congenital
  • Strep-associated (rheumatic heart disease)

Aortic sclerosis

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Aortic sclerosis murmur

Aortic sclerosis is a hard and inflexible aortic valve (thickened, NOT narrowed) due to age-related calcification. This causes turbulence and a local sound only.

  • Character: ejection systolic
  • Best heard: upper right sternal edge
  • Radiation: does not radiate
  • Symptoms: none
  • Signs:
    • No abnormal signs
    • Differentiate from AS by normal pulse, apex and S2

Mitral regurgitation

Mitral regurgitation causes backflow of blood from left ventricle to left atrium during systole. This causes LV and left atrial dilation, which ultimately results in pulmonary hypertension.

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Mitral regurgitation murmur
  • Character: pansystolic
  • Best heard: apex; loudest on expiration
  • Radiation: left axilla
  • Symptoms:
    • Dyspnoea
    • Orthopnoea
    • Paroxysmal nocturnal dyspnoea
    • Fatigue
    • Palpitations
  • Signs:
    • AF
    • Displaced thrusting apex (volume-loaded)
    • Soft S1
    • Signs of pulmonary hypertension (RV heave, loud P2)
    • May be signs of LVF (S3, pulmonary oedema)

Causes of… Mitral regurgitation

  • Papillary muscle dysfunction (post-MI)
  • Dilated cardiomyopathy
  • Rheumatic heart disease
  • Infective endocarditis
  • Congenital
  • Connective tissue disorders (e.g. Marfan’s)

Mitral valve prolapse

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Mitral valve prolapse murmur

Mitral valve prolapse is when a mitral valve leaflet prolapses into the left atrium during ventricular systole.

  • Character: mid-systolic click and/or late systolic murmur
    • Differentiate from MR by normal S1 then gap before murmur
  • Best heard: apex; loudest on expiration
  • Radiation: left axilla and back
  • Symptoms: atypical chest pain
  • Signs:
    • Murmur only
    • Can develop significant MR

Associations of… Mitral valve prolapse

  • Primary congenital
  • Marfan’s syndrome
  • Polycystic kidney disease
  • Congenital heart disease
  • Congestive cardiomyopathy
  • Hypertrophic obstructive cardiomyopathy
  • Myocarditis, Ehlers-Danlos
  • Osteogenesis imperfecta
  • SLE
  • Muscular dystrophy

Ventricular septal defect

A ventricular septal defect results in some blood from the left ventricle leaking into the right ventricle during systole. It is usually congenital (chronic), or due to a myocardial infarction (acute).

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Ventricular septal defect murmur
  • Character: pansystolic loud machinery-like murmur
  • Best heard: lover left sternal edge
  • Radiation: whole precordium
  • Symptoms: often none if small
  • Signs:
    • Signs of pulmonary hypertension (RV heave, loud P2)
    • If acute, may cause cardiogenic shock

Tricuspid regurgitation

Tricuspid regurgitation results in the backflow of blood from the right ventricle to the right atrium during systole. This causes increased right atrial and venous pressure.

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Tricuspid regurgitation murmur
  • Character: pansystolic
    • Differentiate from MR by…
      • louder on inspiration because it’s on the right
      • Giant JVP
      • Non-displaced apex
  • Best heard: lower left sternal edge; loudest on inspiration
  • Radiation: none
  • Symptoms:
    • Fatigue
    • Hepatic pain on exertion
    • Ascites
    • Peripheral oedema
  • Signs:
    • Giant ‘v’ waves in JVP (giant JVP waves without RVF = TR)
    • Backflow signs (peripheral oedema, ascites, pulsatile hepatomegaly)
    • Signs of lung disease and pulmonary hypertension (RV heave, loud P2) if that is the cause

Causes of… Tricuspid regurgitation

  • Most commonly due to RV dilation in pulmonary hypertension (e.g. in chronic lung disease or left heart/valve disease)
  • Rheumatic heart disease
  • Infective endocarditis (IV drug user)
  • Ebstein’s anomaly (if split S1 and S2)

Why don’t you test your knowledge?

Or try some of our 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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