🏥 Stations

🧠 Qbank

📖 Book

😃 More

💳 Pricing

🔒 Dashboard

📖 OSCE Learning

🔒 OSCE Stations

🔒 Qbank

🔐 Membership
Share your insights

Help us by sharing what content you've recieved in your exams


Heart murmurs

Medicine > Cardiovascular

Differential Diagnosis Schema 🧠

Systolic Murmurs

  • Aortic Stenosis: Ejection systolic murmur, best heard over the right second intercostal space, radiating to the carotids; associated with slow-rising pulse and narrowed pulse pressure.
  • Mitral Regurgitation: Pansystolic murmur, best heard at the apex, radiating to the axilla; associated with signs of heart failure.
  • Tricuspid Regurgitation: Pansystolic murmur, best heard at the lower left sternal border; often associated with signs of right heart failure.
  • Pulmonary Stenosis: Ejection systolic murmur, best heard over the left second intercostal space; may be associated with a widened splitting of the second heart sound.
  • Hypertrophic Cardiomyopathy: Ejection systolic murmur, best heard at the left sternal edge, increases with Valsalva maneuver; may have associated features like left ventricular hypertrophy.
  • Ventricular Septal Defect (VSD): Pansystolic murmur, best heard at the left lower sternal border; may be associated with a palpable thrill.
  • Mitral Valve Prolapse: Mid-to-late systolic murmur, best heard at the apex, often preceded by a click.
  • Innocent Murmurs: Soft, short, systolic murmurs without associated symptoms, often found in children and young adults.

Diastolic Murmurs

  • Aortic Regurgitation: Early diastolic murmur, best heard at the left sternal border with the patient leaning forward and in expiration; may be associated with a collapsing pulse and wide pulse pressure.
  • Mitral Stenosis: Mid-diastolic murmur, best heard at the apex with the patient in the left lateral position; often associated with a loud first heart sound (S1) and opening snap.
  • Pulmonary Regurgitation: Early diastolic murmur, best heard over the left second intercostal space; often associated with pulmonary hypertension.
  • Tricuspid Stenosis: Mid-diastolic murmur, best heard at the lower left sternal border; often associated with right heart failure.
  • Austin Flint Murmur: A low-pitched diastolic rumble heard at the apex in severe aortic regurgitation, thought to be due to the regurgitant jet striking the anterior mitral leaflet.

Continuous Murmurs

  • Patent Ductus Arteriosus (PDA): Continuous machinery murmur, best heard below the left clavicle; often associated with a bounding pulse.
  • Arteriovenous Fistula: Continuous murmur, may be heard over the site of the fistula; often associated with a palpable thrill.
  • Venous Hum: Continuous humming murmur, best heard over the neck veins; often benign and seen in children.
  • Coronary Arteriovenous Fistula: Rare cause of a continuous murmur, best heard over the precordium.
  • Ruptured Sinus of Valsalva Aneurysm: Continuous murmur, best heard over the right sternal border; associated with signs of heart failure.
  • Coarctation of the Aorta: May have a continuous murmur over the back, often associated with hypertension and radio-femoral delay.

Key Points in History 🥼

Symptom History

  • Dyspnoea: May indicate heart failure, commonly associated with mitral regurgitation or aortic stenosis.
  • Chest Pain: Angina can be associated with aortic stenosis or hypertrophic cardiomyopathy.
  • Palpitations: Common in mitral valve prolapse and mitral regurgitation.
  • Syncope: Concerning symptom, especially in aortic stenosis or hypertrophic cardiomyopathy; suggests critical outflow obstruction.
  • Fatigue: Non-specific but may be associated with mitral or aortic valve disease, leading to reduced cardiac output.
  • Peripheral Oedema: Suggests heart failure, often seen in tricuspid regurgitation or severe left-sided valve disease.
  • Past Episodes of Rheumatic Fever: Important in the context of mitral stenosis, which may develop years after the initial infection.
  • Infective Endocarditis Risk: History of intravenous drug use, recent dental procedures, or known valve disease increases risk.
  • Fever or Recent Infection: May indicate infective endocarditis, especially with a new murmur.
  • Previous Heart Surgery: Important to identify any history of valve repair or replacement, which may influence the nature of the murmur.
  • Medications: Some drugs can exacerbate murmurs (e.g., beta-blockers in aortic stenosis) or may be a clue to underlying conditions (e.g., anticoagulants for atrial fibrillation).
  • Family History: Consider genetic conditions like hypertrophic cardiomyopathy or congenital valve abnormalities.
  • Occupational History: May identify exposure to risk factors for infective endocarditis or conditions exacerbating valvular heart disease.
  • Social History: Lifestyle factors such as alcohol consumption can influence cardiac function and exacerbate underlying heart disease.
  • Symptoms of Pulmonary Hypertension: Relevant in cases of mitral stenosis or regurgitation, leading to secondary pulmonary hypertension.
  • Exercise Tolerance: A decrease in exercise tolerance may suggest worsening valve disease, especially in conditions like aortic stenosis or mitral regurgitation.
  • Previous Cardiac Investigations: Including results of previous echocardiograms or ECGs, which may provide insight into the progression of valvular disease.
  • Recent Trauma or Injury: Can be relevant in cases of traumatic aortic regurgitation or other post-traumatic cardiac conditions.

Background

  • Past Medical History: Including any history of cardiovascular disease, hypertension, or diabetes, which can predispose to valve disease.
  • Surgical History: Previous heart surgery, especially valve repair or replacement, may be relevant.
  • Drug History: Including any anticoagulant use, which is relevant in patients with valve disease or atrial fibrillation.
  • Family History: Hereditary conditions like hypertrophic cardiomyopathy or congenital valve abnormalities may be relevant.
  • Social History: Lifestyle factors such as smoking, alcohol use, and diet can impact cardiovascular health.
  • Occupational History: Risk factors for infective endocarditis or conditions exacerbating valvular heart disease may be relevant.
  • Allergies: Important to consider especially in relation to contrast agents used in diagnostic imaging or medications for heart disease.
  • Travel History: In cases of infective endocarditis, recent travel may be relevant if it involved regions with higher risk of infection.
  • Immunisation History: Particularly relevant in preventing infections that could exacerbate or cause valvular heart disease, such as rheumatic fever.
  • Dietary Habits: Nutritional status may impact cardiovascular health and influence disease progression.
  • Activity Level: Physical activity may influence symptoms and progression of valvular heart disease.
  • Psychosocial Factors: Stress levels, mental health, and social support can affect management and outcomes in patients with heart disease.
  • Comorbid Conditions: Other chronic illnesses, such as chronic kidney disease or COPD, can complicate the management of heart murmurs.
  • Reproductive History: In women, it’s important to consider the impact of pregnancy on valvular heart disease.

Possible Investigations 🌡️

Initial Assessments

  • Electrocardiogram (ECG): Can identify arrhythmias, evidence of left or right ventricular hypertrophy, or ischaemic changes.
  • Chest X-Ray: May show cardiomegaly, pulmonary oedema, or calcification of the heart valves.
  • Transthoracic Echocardiography (TTE): First-line imaging to assess the structure and function of the heart valves and chambers.
  • Transesophageal Echocardiography (TEE): More detailed than TTE, often used in the assessment of complex valve disease or for detecting infective endocarditis.
  • Blood Tests: Full blood count, renal function, liver function, and inflammatory markers (e.g., CRP, ESR) are relevant in assessing overall health and in conditions like infective endocarditis.
  • BNP or NT-proBNP: Biomarkers of heart failure, which may be elevated in significant valvular heart disease.
  • Cardiac MRI: Provides detailed imaging of the heart’s structure and function, especially useful in complex cases or where echocardiography is inconclusive.
  • Stress Testing: May be used to assess the functional significance of a valve lesion, particularly in aortic stenosis or mitral regurgitation.
  • Holter Monitoring: Useful in detecting arrhythmias that may be associated with valve disease.
  • Cardiac Catheterisation: Invasive procedure to assess coronary artery disease and measure intracardiac pressures, often used before valve surgery.
  • Doppler Ultrasound: Assesses blood flow across the valves, helping to quantify the severity of stenosis or regurgitation.
  • Cerebral Imaging: Consider in patients with suspected embolic phenomena secondary to infective endocarditis or aortic stenosis.
  • Exercise Echocardiography: Can help assess valve function during physical stress, particularly in asymptomatic patients with severe valve disease.
  • Liver Function Tests: Especially relevant in right-sided heart failure, where hepatic congestion may occur.
  • Renal Ultrasound: Consider if there is suspicion of renal complications from chronic heart failure or systemic emboli.
  • Pulmonary Function Tests: Useful in differentiating between cardiac and pulmonary causes of dyspnoea in patients with valvular heart disease.
  • Arterial Blood Gas (ABG): In cases of severe heart failure, ABG can help assess respiratory function and acid-base balance.
  • Genetic Testing: Consider in familial cases of hypertrophic cardiomyopathy or congenital valve disease.
  • Nuclear Imaging: Such as a myocardial perfusion scan, may be used to assess the impact of valvular disease on myocardial perfusion.
  • Coronary Angiography: Indicated in patients with symptoms suggestive of ischaemic heart disease or before valve surgery.
  • Endomyocardial Biopsy: Rarely indicated but may be useful in specific cases of unexplained heart failure or myocarditis associated with valve disease.
  • PET Scan: May be indicated in cases of suspected infective endocarditis to assess for metastatic infection.
  • CT Coronary Angiography: Non-invasive alternative to invasive coronary angiography, particularly useful in patients with lower risk of coronary artery disease.

No comments yet 😉

Leave a Reply

Cardiovascular