Cardiac Murmers

Lejay Jacob Presentation during Pediatric Rotation w/

Dr. Luis F. Santiago, M.D.

October 21st, 2014

by

Thought process

• Timing, - Is it Systolic/Diastolic • Location

• Specific Description of murmer -Shape, Pitch, Quality, Radiation, Grading

5th ICS In MCL

Image Source- http://www.aafp.org/afp/2011/1001/p793.html

Note: Orange text , following , describes terms indicating Quality

Overview

Murmers

Systolic Diastolic

M St

T St

A R

P R

M R

T R

A St

P St

ASD

VSD

Septal Defect

Flow Murmer =Anemia

HOCM

Continuous = PDA

MVP

Mnemonic MR ASS(ystolic) MS ARD(iastolic) Think of Aortic/Pulm Valves Together, time of Closing Mitral/ Tricuspid Valves

Mnemonic source- Fernando Catalan

Physiology , Variations of Murmers

• Increased velocity of Blood

-Through morphologically Normal Structures

-Through narrowed structures, velocity increases with square of radius

• Decreased Viscosity of Blood

-Notable in Anemic p/ts

• Variation of Heart Murmer

- AKA Bruits in Veins , in the carotid Arteries , Abdominal Aortic Aneurysm

Innocent heart Murmer criteria*, PEDs >1 y.o.

• absence of abnormal physical examination findings (except for the murmur);

• a negative review of systems (i.e., child is asymptomatic, parents report of time Child plays);

• a history that is negative for features that increase the risk of structural heart disease;

• characteristic auscultatory features of a specific innocent heart murmur.

> If above criteria not met, refer to EKG And OR pediatric cardiologist.

>Other orders suggested- CBC, Chest Xray

Note-In this presentation, the term Innocent is Synonymous with term, Benign

* According to criteria in Article Evaluation and Management of Heart Murmers in Children , See Source Slide

Benign Pediatrics Related Murmers

Stills Early systolic Grade 1-3 Tricuspid and mitral V Twang sound , increase with supine Decrease with sitting up Rarely in infants, most likely 2-6 y.o

Pulm flow Grade 2-3 Systolic Ej murmer Pulm V Harsh, intensity increase with supine Young children to young adulthood

Peripheral Pulm artery Sten

Grade 1-2 Mid Syst Medium pitch, increase w/ supine Back and axilla Newborn , and <1y.o + recovering viral resp infxn

Supraclavicular Or Brachiocephalic

Syst Med pitch Clavicles, radiate to neck Rapid shoulder extension can dec Intensit Any Age child

Aortic Syst Non harsh Aortic V In p/t with High Heart Output Volume

Systolic Venous Hum Grade 1-6

Diastole Continuous Loud on right side , supra /infra clavicular area, increase when sitting up and looking away from you Decrease when Supine Compression of internal jugular may decrease it 3-6 y.o

Mammary souffle murmer Continuous murmer High pitch, intensity varies daily Over Anterior Breast In lactating Mothers

PDA Physiologic in newborns, pathologic if persist Continuous machine like murmer, diamond shape

Continuous

“Knowing appearance(s)of Normal is First step of Finding what’s wrong” - Anon

Image Source- University of Utah, http://library.med.utah.edu/kw/pharm/hyper_heart1.html

Systolic

T R VSD

Valve defect Specific Descriptions

ASD Wide fixed Splitting L->R Shunt

VSD Harsh Holosystolic

MR M V Prolapse

Holosystolic Blowing/ Musical Radiation to Axilla Pronounced with Increase in After Load Midsystolic Click, follow by crescendo decresc At Apex Enhanced by Valsalva, decreased by Squatting Contrary to other murmers , also seen HOCM

TR Holosystolic Present on Left; Radiation to Rt Sternal Border Inpiration Increases Right side murmers

ASt Pulsus Parvus et Tardus Early Systolic Click Harsh sound Seen in old age OR Bicuspid Aortic Valve

PSt HOCM

Related to Tetrology of Fallot Decreased intensity with sustained Squat

PSt

Image- Master the boards, USMLE Step 2 CK, 2nd ed

Note- Pay attention To Clicks and Snaps shown in Red

Overview

Diastolic and Continuous

Valve Defect Specific Description

MSt Opening Snap Rumbling Note- for immigrants with a delayed or unverified vaccination Hx= Could have had Rh Heart Dis

TSt A Rt sided Heart Defect Affected In IV Drug abusers and Rheumatic Heart Disease

AR AKA Aortic Insufficiency

Blowing Murmer Wide pulse pressure, Lower diastolic pressure

PR A Rt sided Heart Defect Affected In IV Drug abusers and Rheumatic Heart Disease

PDA Continuous Machine Like murmer

PDA

T St

P R A R Aortic Insufficiency

Blue Images- http://www.stritch.luc.edu/lumen/MedEd/MEDICINE/PULMONAR/PD/heart%20murmurs.ppt

Overview

General Details

• Radiations - Bruits and murmers radiate In the Direction of Blood Flow - Aortic Valve defects radiate to Carotid Arteries - Tricuspid V Defects radiate to Ant Thorax sternal borders - Mitral V Defects radiate to mid clavicular Line • Order of Preference of Valves affected in Rheumatic Heart Disease 1) Mitral V 2) Aortic V 3) Tricuspid V • Diastolic Murmers are generally pathologic*

• Grading

– graded on a 6 point scale

• Grade 1 = very faint

• Grade 2 = quiet but heard immediately

• Grade 3 = moderately loud

• Grade 4 = loud

• Grade 5 = heard with stethoscope partly off the chest

• Grade 6 = no stethoscope needed

*Note: Thrills are assoc. with murmurs of grades 4 – 6

* Article: Approach to Cardiac Murmers - see Sources Slide

Maneuvers Change in Afterload

Pressure in Pulmonic Circulation is seen with Pulmonary HT, sign of SOB, Increase HR

Pressure in Aortic/Systemic Circulation is increased

with Hand Fist, Sustained Squat(30 Sec)

Change in Preload

Inspiration , causes increase in Preload , blood to Right side of heart, pronounced RH murmers

Fast Squat, Increase Venous Return and Diastolic Filling

Another way to increase RH murmers is to make p/t Lie down Supine

Expiration, increases Lt heart murmers

Valsalva Maneuver/ standing

Done by asking p/t to close nose and mouth and blow like blowing balloon

Increases Vasovagal Rxn , Increases PSNS tone, decrease HR and BP

Decrease Volume of Left Ventricle

Lateral Decubitis Position

Accentuates Mitral Murmers

Sitting Forward and Exhaling Completely

Accentuates Aortic Murmers , decrease HR , Increase Stroke Volume

Carotid massage, decrease HR, PSNS

Simultaneous Carotid massage, can cause Syncope

Named Murmers, Wards and Clinical Importance

Eponym Description

Austin Flint murmer Mid to Diastolic rumble , heard in AR Can mimic MS

Graham Steel murmer PR occurring with Pulm HT High pitch and Blowing

Carey Coombs murmer Mid diastolic , at Apex, During Acute Rheumatic Fever

Gallavardin Phenomonen Highest frequencies of AS murmer , radiate to apex, Mimic MR

Dock’s Murmer Diastolic, heard w/ stenosis of LAD

Case 1

• A 1 mth old female infant born at full term is noted to have a harsh holosystolic 3/6 heart murmer heard best at lower sternal border . The child is not cyanotic and does not have hepatomegaly or tachypnea at rest . The child feeds without tachypnea or diaphoresis, and weight gain is appropriate. There is no cardiomegaly on chest Xray , Which of the following is most likely Dx?

• A) VSD • B)ASD • C) PDA • D) P St • F) A St

Sound

Ans. 1

Source

• Evaluation and Management of Heart Murmers in Children by Frank, Jennifer E, MD and Jacobe, Kathyryn M. MD, accessed on October 10th, 2014.

http://www.aafp.org/afp/2011/1001/p793.html • Approach To Cardiac Murmers by Nabi, Shahin M . Ed by Bishop, Jeff. Accessed on

October 15th, 2014 http://learnpediatrics.com/body-systems/cardiology/approach-to-cardiac-murmurs/ • Kaplan Step 1 Lecture CD ,2007 set, Cardiology, Murmers video- Dr Wasir Kudrath,

MD • Heart murmers for USMLE step 1 video, Youtube –Joseph Benidict, Eric strong,MD • Blueprints for Pediatrics , 3rd edition. • Master the Boards, USMLE Step 2 CK, 2nd edition. • Heart murmer Library accessed on October 10th ,2014 - http://www.med.umich.edu/lrc/psb/heartsounds/index.htm Question 1 Sound -http://www.easyauscultation.com/holosystolic-murmur • Background image-

http://www.aubmc.org/patientcare/spe_cli_pro_ser/Pages/chc.aspx

Thank You