MURMURS

Bear in mind all valve dz can eventually lead to LVF (except MS?) and MR can lead to RVF (plus all LVF can
anyway?)
General principles

Then use All Prostitutes Enjoy Taking Money (E is Erbs point best for AR)
Radiation: AS to the carotids, MR to the axilla

Quiet heart sounds: Can be caused by valves opening slower (stenosis) or less forcefully (regurgitation). Soft S1
(AV valves) = MR, MS.
Soft S2 (Semilunar valves): AS, AR

AS Calcification. S&S >60 (exam: M) Pulse: Parvus et tardus, narrow pulse presure
follow on logically, Classic triad*: Apex: Heave, non- displaced (LVH)
squeezing a hose Syncope Murmur: Systolic ejection, crescendo-
CO /LVH: Mn SAD Angina decrescendo. Best heard Rt. Upper sternal border,
- Stenosis of AV Dyspnoea radiating to carotids
Dyspnoea HS: S2 quiet
Eponymous: none
AR Pts dont usually present Pulse: Corrigans Collapsing, Water Hammer,
Marfans, Ank spon (one with symptoms until wide pulse pressure
of the As), Rheumatic LVF develops Apex: 6th ICS, ant. axillary line, thrusting
fever Later: Chronic volume Murmur: Diastolic early descrendo
overload leads to LV Eponymous signs:
failure and CHF. Corrigans collapsing carotid
Angina, Quinckes: Nail bed pulsations
symptoms of aortic Austin Flint murmur
dissection (e.g. chest
pain radiating to back).

MR Many causes* Dyspnoea Pulse: ?AF, CXR: Cardiomeg

most common: mitral Dec. ex. Tolerance Apex: Displaced eccentric RVH, ?Heave ECG**
valve prolapse syndrome None specific to MR Murmur: Pansystolic. Best heard at apex, rad. to
. Also MI, HF, S&S of CCF: e.g. axilla
Rheumatic fever oedema, PND HS: S1 quiet
S&S of AF
Acute: medical
emergency - sudden
pulmonary congestion
with no compensation
Chronic: Fatigue,
dyspnoea, orthopnoea,
PND (pulmonary
congestion)
Chronic MR initially
asymptomatic. Fatigue
(due to forward CO),
exertional dyspnoea,
orthopnoea, systemic
embolization (less
 common than MS).
Palpitations ( stroke
volume/associated AF).
Right heart failure in
later stages

Mitral prolapse not F>M (~10% of F) Murmur: Systolic with mid systolic click
clear, assoc. with (Examiner trick MR vs MP: If there is a click =
Marfans, Ehlers danlos MP
MS Rheumatic Dyspnoea (pulmonary malar flush
fever/heart dz congestion) Pulse: weak/irregular (AF)
orthopnea, PND, Apex beat: not displaced , tapping (d/t extra force
haemoptyis (capillary required to close valve)
rupture) - this one has Lungs: lung creps
the most extreme
pulmonary
congestion/back pressure
so causes bronchitis like
picture

AR Pulse: Corrigans Collapsing, Water Hammer,

wide pulse pressure

Murmur: Diastolic early descrendo

Atrial Fibrillation
thyrotoxicosis, ischaemic
heart disease,
pneumonia, sepsis and
mitral stenosis

AS
Angina pectoris: from O 2 demand due to LVH Syncope: on exertion cannot increase CO in setting of
peripheral vasodilation leading to cerebral perfusion Dyspnoea: pulmonary oedema causing dyspnoea
(exacerbated by AF).

MR
The mitral valve apparatus consists of anterior and posterior leaflets, chordae tendineae, papillary muscles, and
mitral annulus. Any aberrations of the mitral valve apparatus, due to mechanical, traumatic, infectious,
degenerative, congenital, or metabolic causes, may lead to mitral regurgitation

MS
StenosisLA pressure/volAF and pulmonary venous pressure pulmonary oedema

Right heart murmurs

Tricuspid stenosis IV Drug abuse Oedema
infective Hx of infective (peripheral) d/t
endocarditis endocarditis venous HTN
Pulmonary stenosis
Congenital