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| ! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Disease Resident Survival Guide Microchapters}}
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Heart murmur resident survival guide#Overview|Overview]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Heart murmur resident survival guide#Causes|Causes]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Heart murmur resident survival guide#Diagnosis|Diagnosis]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Heart murmur resident survival guide#Treatment|Treatment]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Heart murmur resident survival guide#Do's|Do's]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Heart murmur resident survival guide#Don'ts|Don'ts]]
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| |}
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| __NOTOC__
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| {{WikiDoc CMG}}; {{AE}}{{Nuha}}
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| ==Overview==
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| A Heart murmur is an abnormal [[heart sounds|heart sound]] produced as a result of turbulent blood flow, which is sufficient to produce audible noise, defined as a relatively prolonged series of auditory vibrations of varying intensity (loudness), frequency (pitch), quality, configuration, and duration. Murmurs could be [[systolic]] or [[diastolic]] or [[continuous murmur]].
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|
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| ==Causes==
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| ===Life Threatening Causes===
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| Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
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| * [[Papillary muscle]] rupture complicating [[acute myocardial infarction]]
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| * Rupture of [[chordae tendineae]].
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| * [[Infective endocarditis]]
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| * Blunt [[chest wall]] trauma
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|
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| ===Common Causes===
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| * [[Systolic murmur]]<ref name="pmid21250186">{{cite journal| author=Walker HK, Hall WD, Hurst JW| title=Clinical Methods: The History, Physical, and Laboratory Examinations | journal= | year= 1990 | volume= | issue= | pages= | pmid=21250186 | doi= | pmc= | url= }} </ref>
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| **[[Ejection murmurs]]
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| ***Functional
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| ****[[Still's murmur]] and its adult variant
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| ****Flow [[murmur]] emanating from the root of the [[pulmonary artery]]
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| ****[[Murmur]] associated with high [[cardiac output]] states
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| ****Flow murmurs associated with aortic or pulmonary valvular insufficiency
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| ***Organic
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| ****Valvular [[aortic stenosis]]
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| ****[[Aortic sclerosis]]
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| ****Discrete [[subvalvular aortic stenosis]] (web or tunnel)
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| ****[[Supravalvular aortic stenosis]]
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| ****[[Hypertrophic obstructive cardiomyopathy]]
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| ****[[Pulmonary valvular stenosis]]
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| ****[[Pulmonary infundibular stenosis]]
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| ****[[Atrial septal defect]]
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| ****[[Tetralogy of Fallot]]
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| **Regurgitant murmurs
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| ***Functional: none
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| ***Organic:
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| ****[[Mitral regurgitation]]:
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| *****Rheumatic
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| *****[[Papillary muscle]] dysfunction
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| *****[[Mitral valve prolapse]]
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| *****Acute
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| ****[[Tricuspid regurgitation]]:
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| *****Chronic
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| *****Acute
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| ****[[Ventricular septal defect]]
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| *****Roger's type (small and large)
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| ******Without [[pulmonary hypertension]]
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| ******With [[pulmonary hypertension]]
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| *****Slitlike
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| ***Extracardiac sounds simulating [[systolic heart murmurs]]
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| ****Subclavian (supraclavicular/brachiocephalic) [[Murmur]]
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| ****Internal mammary soufflé
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| ****[[Carotid artery bruits]]
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| ****[[Coarctation of the aorta]]
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| ****Murmurs emanating from a dilated aortic or pulmonary artery root
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| ****[[Patent ductus arteriosus]] with [[pulmonary hypertension]] <br />
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| *[[Diastolic murmur]]<ref name="pmid21250187">{{cite journal| author=Walker HK, Hall WD, Hurst JW| title=Clinical Methods: The History, Physical, and Laboratory Examinations | journal= | year= 1990 | volume= | issue= | pages= | pmid=21250187 | doi= | pmc= | url= }} </ref>
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| **[[Aortic regurgitation]]
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| **[[Pulmonary valve regurgitation]]
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| **Mitral rumble
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| ***Obstruction to flow
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| ****[[Mitral stenosis]] (rheumatic, congenital)
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| ****[[Left atrial myxoma]]
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| ****Cor triatriatum
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| ****Localized pericardial constriction
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| ***Increased flow
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| ****[[Mitral regurgitation]]
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| ****[[Ventricular septal defect]]
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| ****[[Patent ductus arteriousus]]
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| ****[[Complete heart block]]
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| **Tricuspid rumble
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| ***Obstruction to flow
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| ****[[Tricuspid stenosis]] (rheumatic, Ebstein's anomoly, carinoid)
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| ****[[Right atrial myxoma]]
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| ****Localized pericardial constriction
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| ***Increased flow
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| ****[[Atrial septal defect]]
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| ****[[Tricuspid regurgitation]]
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| *[[Continuous murmur]] <ref name="pmid22574086">{{cite journal| author=Ginghină C, Năstase OA, Ghiorghiu I, Egher L| title=[[Continuous murmur]]—the auscultatory expression of a variety of pathological conditions. | journal=J Med Life | year= 2012 | volume= 5 | issue= 1 | pages= 39-46 | pmid=22574086 | doi= | pmc=3307079 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22574086 }} </ref>
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| **THORACIC:
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| ***[[Precordial]]
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| ****[[Patent ductus arteriosus]]
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| ****[[Coronary arteriovenous fistulas]]
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| ****Sinus of Valsalva aneurysm ruptured into right cavities
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| ****[[Atrial septal defect]] associated with abnormalities that cause increased pressure in the [[left atrium]]
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| ****[[Left coronary artery]] origin from [[pulmonary artery]] anomaly
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| ****[[Continuous murmur]] at intern mammary artery
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| ***Extra [[Precordial]]
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| ****[[Coarctation of the aorta]]
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| ****[[Pulmonary atresia]]
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| ****[[Pulmonary arteriovenous fistula]]
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| ****[[Truncus arteriosus]]
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| ****Anomalies of origin of the [[pulmonary artery]]
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| **EXTRATHORACIC:
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| ***[[Venous hum]]
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| ***Cruveilhier-Baumgarten sindrom
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| ***Severe arterial stenosis
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| *** Extrathoracic arteriovenos fistulas
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|
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| ==Diagnosis==
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| Shown below is an algorithm summarizing the Approach to the Heart Murmurs according to ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease.<ref name="BonowCarabello2006">{{cite journal|last1=Bonow|first1=Robert O.|last2=Carabello|first2=Blase A.|last3=Chatterjee|first3=Kanu|last4=de Leon|first4=Antonio C.|last5=Faxon|first5=David P.|last6=Freed|first6=Michael D.|last7=Gaasch|first7=William H.|last8=Lytle|first8=Bruce Whitney|last9=Nishimura|first9=Rick A.|last10=O’Gara|first10=Patrick T.|last11=O’Rourke|first11=Robert A.|last12=Otto|first12=Catherine M.|last13=Shah|first13=Pravin M.|last14=Shanewise|first14=Jack S.|title=ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease|journal=Circulation|volume=114|issue=5|year=2006|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.106.176857}}</ref>
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| <span style="font-size:85%"> '''Abbreviations:''' '''AR: [[Aortic regurgitation]]''', '''AS:[[Aortic stenosis]]''', '''COP:[[Cryptogenic organizing pneumonia]]'''
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| , '''HOCM:[[ Hypertrophic cardiomyopathy]]'''
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| , '''JVP: [[Jugular venous pressure]]'''
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| , '''MR:[[Mitral regurgitation]]'''
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| , '''MVP: [[Mitral valve prolapse]]'''
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| , '''PAH:[[Pulmonary hypertension]]'''
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| , '''PR:[[ Pulmonic regurgitation]]'''
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| , '''PS:[[Pulmonary stenosis]]'''
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| , '''TR: [[Tricuspid regurgitation]]'''
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| , '''TS: [[Tricuspid stenosis]]'''
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| , '''TTE:[[Echocardiography]]'''
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| , '''VSD:[[Ventricular septal defect]]'''
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| </span>
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| <small><small><small><small>
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| {{Family tree/start}}
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| {{familytree | | | | | | A01 | | | | | | | | | | | |A01=<div style="float: left; text-align: left; padding:1em;">'''Obtain a Detailed History'''<br> <div class="mw-collapsible mw-collapsed">The history, and associated physical examination findings provide additional clues by which the significance of a [[heart murmur]] can be established<br> Accurate bedside identification of a [[heart murmur]] can inform decisions regarding the indications for noninvasive testing and the need for referral to a [[cardiovascular]] specialist.<br> ❑ Address specific patient symptoms and complaints<br> ❑ Obtain review of systems relevant to [[Cardiovascular system]]<br> ❑ [[Headache]]<br> ❑ [[Dizziness]]<br> ❑ [[Syncope]]/[[presyncope]]<br> ❑ [[Chest pain]] / [[Angina]]<br> ❑ [[Palpitations]]<br> ❑ [[Dyspnea]]<br> ❑ [[Cough]]<br> ❑ [[Abdominal pain]]<br> ❑ [[Peripheral edema]]<br> ❑ [[Dyspnea]] on exertion<br> ❑ [[Fatigue]]<br> ❑ [[Orthopnea]]<br> ❑ [[Paroxysmal nocturnal dyspnea]]<br> '''Past Medical History'''<br> ❑ History of previous medical diagnoses / past medical complaints / hospitalizations and surgeries<br> ❑ [[Cardiovascular disease]]<br> ❑ [[Hypertension]]<br> ❑ [[Bicuspid aortic valve]]<br> ❑ [[Rheumatic fever]]<br> ❑ History of [[diabetes mellitus]]<br> '''Medications'''<br> ❑ Current prescribed medications<br> ❑ Previous intake of medications and reason for discontinuation<br>❑ History of drug adverse effects<br> '''Allergies'''<br>❑ Known drug allergies<br> ❑ Known environmental/food allergies<br> '''Family history'''<br> ❑ Family history of [[cardiovascular disease]]<br> '''Social History'''<br> ❑ Overall living situation<br> ❑ Occupation<br> ❑ Exercise<br> ❑ Diet (general)<br> ❑ Smoking history<br> ❑ Alcohol use<br> ❑ Recreational drug use<br> ❑ Stress<br> ❑ Sexual lifestyle & [[contraceptive]] methods}}
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| {{familytree | | | | | | |!| | | | | | | | | | | | | | }}
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| {{familytree | | | | | | B01 | | | | | | | | | | | | |B01=<div style="float: left; text-align:center; padding:1em;">'''Examine the patient:'''<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed"><br> <div style="float: left; text-align: left; padding:1em;"> ❑ [[Pulse]]<br> Rate, rhythm, and characteristics include contour and amplitude of the pulse like (Water hammer pulse in AR)<BR> ❑ [[Blood pressure]]<br> ❑ [[Temperature]]<br> ❑ [[Respiratory rate]]<br>
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| ❑ [[Skin]]:<br>
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| :❑ [[Cyanosis]]<br>
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| :❑ [[Edema|Peripheral edema]]<br>
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| ❑ [[Nails]]:<br>
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| :❑ [[Splinter hemorrhages]].<br>
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| ❑ [[Mouth]]:
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| :❑ Palatal [[petechiae]] associated with [[infective endocarditis]].<br>
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| :❑ A high arched palate is associated with [[congenital heart disease]], such as [[MVP]]<br>
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| ❑ [[Neck]]:<br>
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| :❑ [[JVP]] can lead towards diseases such as [[atrial fibrillation]],[[TR]],[[TS]],[[PAH]], [[PS]]<br>
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| ❑ [[Cardiovascular system]]:<br>
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| :❑ Palpation: includes assessing the [[arterial pulse]], measuring [[blood pressure]], palpating any [[thrills]] on the chest, and palpating for the point of [[maximal impulse]].<br>
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| :❑ Auscultation: is the cornerstone, auscultate the four standard positions; supine, left lateral decubitus, upright, upright leaning forward.<br> If a [[murmur]] is present, the following features require inspection; timing, location, radiation, duration, intensity, pitch, quality, relation to [[respiration]], and maneuvers such as [[Valsalva]] or [[hand grip]].<br>
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| ❑ [[Respiratory system]]:<br>
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| :❑ [[Crackles]] or [[rales]]<br>
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| :❑ [[Tachypnea]]<br>
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| ❑ [[Abdominal system:]]<br>
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| :❑ [[Hepatojugular reflex]]<br>
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| :❑ [[Hepatomegaly]] <br>
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| :❑ [[Ascites]]<br>}}
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| {{familytree | | | | | | |!| | | | | | | | | | | | | | }}
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| {{familytree | | | | | | B01 | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Obtain the whole features of the [[murmur]]'''<BR><div class="mw-collapsible mw-collapsed">❑ '''The accurate timing of [[heart murmurs]] is the first step in their identification.'''<BR>
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| ❑ '''Duration and Character:'''<BR>
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| The configuration of a [[heart murmur]] may be described as crescendo, decrescendo, crescendo-decrescendo, or plateau.<BR>
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| ❑ '''Intensity'''<BR>
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| :❑ The intensity of a [[heart murmur]] is graded on a scale of 1–6<br>
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| ::❑ A grade 1 [[Murmur]] is very soft and is heard only with great effort.<br>
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| ::❑ A grade 2 [[Murmur]] is easily heard but not particularly loud.<br>
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| ::❑ A grade 3 [[Murmur]] is loud but is not accompanied by a palpable [[thrill]] over the site of maximal intensity.<br>
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| ::❑ A grade 4 [[Murmur]] is very loud and is accompanied by a thrill.<br>
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| ::❑ A grade 5 [[Murmur]] is loud enough to be heard with only the edge of the stethoscope touching the chest.<br>
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| ::❑ A grade 6 [[Murmur]] is loud enough to be heard with the stethoscope slightly off the chest.<br>
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| :❑ [[Murmur]]s of grade 3 or greater intensity usually signify important structural [[heart disease]].<br>
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| :❑ The intensity of a [[heart murmur]] may be diminished by any process that increases the distance between the intracardiac source and the stethoscope on the [[chest wall]], such as [[obesity]], [[obstructive lung disease]], and a large [[pericardial effusion]]. The intensity of a [[murmur]] also may be misleadingly soft when [[COP]] is reduced significantly or when the pressure gradient between the involved [[cardiac]] structures is low.<br>
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| ❑ '''Location and Radiation'''<br>
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| :❑ Recognition of the location and radiation of the [[murmur]] helps facilitate its accurate identification.<br>
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| :❑ Adventitious sounds, such as a [[systolic click]] or [[diastolic snap]], or abnormalities of [[S1]] or [[S2]] may provide additional clues.<br>
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| ❑ '''Interventions Used to Alter the Intensity of [[Cardiac Murmurs]]’’’<br>
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| :❑ [[Respiration]]:<br> Right-sided [[murmurs]] generally increase with [[inspiration]]. Left-sided murmurs usually are louder during [[expiration]].<br>
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| :❑ [[Valsalva maneuver]]:<br> Most [[murmurs]] decrease in length and intensity. Two exceptions are the [[Heart murmur|systolic murmur]] of [[HCM]], which usually becomes much louder, and that of [[MVP]], which becomes longer and often louder.<br>
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| :❑ [[Exercise]]:<br> [[Murmurs]] caused by [[blood flow]] across normal or obstructed [[valves]] (e.g., [[PS]] and [[MS]]) become louder with both isotonic and isometric (handgrip) exercise. [[Murmurs]] of [[MR]], [[VSD]], and [[AR]] also increase with [[handgrip exercise]].<br>
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| :❑ Positional changes:<br> With standing, most [[murmurs]] diminish, 2 exceptions being the [[murmur]] of [[HCM]], which becomes louder, and that of [[MVP]], which lengthens.<br> With brisk squatting, most [[murmurs]] become louder, but those of [[HCM]] and [[MVP]] usually soften and may disappear.<br> Passive leg raising usually produces the same results as brisk squatting.<br>
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| :❑ Pharmacological interventions:<br> During the initial relative [[hypotension]] after [[amyl nitrite]] [[inhalation]], [[murmurs]] of [[MR]], [[VSD]], and [[AR]] decrease, whereas murmurs of [[AS]] increase. During the later [[tachycardia]] phase, [[murmurs]] of [[MS]] and right-sided lesions also increase. This intervention may thus distinguish the [[Austin Flint murmur]] from that of [[MS]]. The response in [[MVP]] often is biphasic.<br>}}
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| {{familytree | | | | |,|-|^|-|-|-|-|-|-|-|-|-|-|-|-|-|v|-|-|-|-|-|-|-|-|-|-|-|-|.| }}
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| {{familytree | | | | C01 | | | | | | | | | | | | | | C02 | | | | | | | | | | | C03 |C01=<div style="float: left; text-align: center; width: 15em; padding:1em;">'''[[Heart murmur|Systolic Murmur]]'''|C02=<div style="float: left; text-align: center; width: 32em; padding:1em;">'''[[Heart murmur|Diastolic murmur]]'''|C03=<div style="float: left; text-align: center; width: 15em; padding:1em;">'''[[Heart murmur|Continuous murmur]]'''}}
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| {{familytree | | | | |!| | | | | | | | | | | | | | | |!| | | | | | | | | | | | |!| |}}
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| {{familytree | | | | |!| | | | | | | | | | | | | | | |!| | | | | | | | | | | | |!| |}}
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| {{familytree | | | | |!| | | | | | | | | | | | | | | |!| | | | | | | | | | | | |!| |}}
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| {{familytree | |,|-|-|^|v|-|-|-|v|-|-|-|.| | | | |,|-|^|-|-|-|-|.| | | | | | | |!| |}}
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| {{familytree | |!| | | |!| | | |!| | | |!| | | | |!| | | | | | |!| | | | | | | |!| |}}
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| {{familytree | C01 | | C06 | | C05 | | C07 | | | C02 | | | | | C03 | | | | | | C04 |C01=<div style="left; text-align: left; width: 28em; padding:1em;">'''Early [[Heart murmur|Systolic Murmur]]'''<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed"><br>
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| ❑ '''[[Acute, severe MR]]'''<br>
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| :❑ Early, decrescendo [[Heart murmur|systolic murmur]] best heard at or just [[medial]] to the [[apical impulse]]. <br>
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| :❑ It could be due to [[papillary muscle]] rupture complicating [[acute myocardial infarction]], rupture of [[chordae tendineae]] in the setting of [[myxomatous mitral valve disease]],[[infective endocarditis]] and blunt [[chest wall]] trauma.<br>
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| :❑ [[TTE]] is indicated in all cases of suspected [[acute, severe MR]] to define its mechanism and severity, delineate [[left ventricular]] size and [[systolic]] function, and provide an assessment of suitability for primary valve repair.<br>
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| ❑ '''[[VSD|A congenital, small muscular VSD]]'''<br>
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| :❑ The defect closes progressively during septal contraction, and thus, the [[murmur]] is confined to early [[systole]].<br>
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| :❑ It is localized to the [[left sternal border]] and is usually of grade 4 or 5 intensity.<br>
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| :❑ Signs of [[pulmonary hypertension]] or [[left ventricular]] [[volume overload]] are absent.<br>
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| ❑ '''Large and uncorrected [[VSD]] associated with [[pulmonary hypertension]].'''<br>
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| :❑ The [[murmur]] best heard along the [[left sternal border]] but is softer and signs of [[pulmonary hypertension]] (right ventricular lift, loud and single [[S2]]) may predominate.<br>
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| :❑ Suspicion of a [[VSD]] is an indication for [[TTE]].<br>
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| ❑ '''[[Tricuspid regurgitation]] with normal [[pulmonary artery]] pressures (due to [[infective endocarditis]]).'''<br>
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| :❑ The [[murmur]] is soft (grade 1 or 2), is best heard at the lower left sternal border, and may increase in intensity with [[inspiration]] ([[Carvallo’s sign]]).<br>
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| :❑ Regurgitant “c-v” waves may be visible in the [[JVP]].<br>
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| :❑ [[TR]] in this setting is not associated with signs of [[right heart failure]].<br>|C06=<div style="float: left; text-align: left; width: 28em; padding:1em;">'''[[Holosystolic murmur]]'''<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed"><br>❑ [[Chronic mitral regurgitation]]<br>
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| :❑ The [[holosystolic murmur]] of [[chronic MR]] is best heard at the [[left ventricular apex]] and radiates to the [[axilla]]; it is usually high-pitched and plateau in configuration.<br>
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| :❑ In contrast to [[acute MR]], left atrial compliance is normal or even increased in [[chronic MR]].<br>
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| :❑ [[Chronic severe MR]] results in enlargement and leftward displacement of the [[left ventricular apex]] beat.<br>
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| ❑ [[Chronic tricuspid regurgitation]]<br>
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| :❑ The [[murmur]] is softer than that of [[MR]].<br>
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| :❑ Loudest at the left lower sternal border, and usually increases in intensity with [[inspiration]] (Carvallo’s sign). <br>
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| :❑ Associated signs include c-v waves in the [[JVP]], an enlarged and pulsatile [[liver]], [[ascites]], and [[peripheral edema]].<br>
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| ❑ [[VSD]]<br>
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| :❑ The [[murmur]] of a [[VSD]] is loudest at the mid- to lower left sternal border and radiates widely. A [[thrill]] is present at the site of maximal intensity. There is no change in the intensity of the [[murmur]] with [[inspiration]]. The intensity of the [[murmur]] varies as a function of the anatomic size of the defect.|C05=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''[[hreat murmur|Midsystolic Murmur]]'''<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed"><br>
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| ❑ [[Aortic stenosis]] the most common cause of a [[hreat murmur|mid-systolic murmur]] in an adult.<br>
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| :❑ The [[murmur]] loudest to the right of the [[sternum]] in the [[second intercostal space]] (aortic area) and radiates into the [[carotids]].<br>
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| :❑ Usually crescendo-decrescendo in configuration.<br>
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| :❑ To differentiate between the apical [[systolic murmur]] from [[MR]] and [[AS]], the murmur of [[AS]] will increase in intensity, in the beat after a premature beat, whereas the murmur of [[MR]] will have constant intensity from beat to beat.<br>
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| :❑ In case of severe [[AS]] a [[hreat murmur|systolic thrill]] and a grade 4 or higher [[murmur]] could be heard, Other auscultatory findings of severe [[AS]] include a soft or absent [[A2]], paradoxical splitting of [[S2]], an apical [[S4]], and a late-peaking [[systolic murmur]].<br>
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| :❑ In children, adolescents, and young adults with [[congenital valvular AS]], an early [[ejection sound]] (click) is usually audible, more often along the left sternal border than at the base. Its presence signifies a flexible, noncalcified valve and localizes the left ventricular outflow obstruction to the valvular (rather than sub- or supravalvular) level.<br>
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| :❑ [[TTE]] is indicated to assess the anatomic features of the [[aortic valve]], the severity of the stenosis, left ventricular size, wall thickness and function, and the size and contour of the aortic root and proximal ascending aorta.<br>
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| ❑ Hypertrophic cardiomyopathy ([[HOCM]])<br>
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| :❑ The [[Heart murmur|mid-systolic murmur]] that is usually loudest along the left sternal border or between the left lower sternal border and the apex.<br>
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| :❑ The intensity of the murmur may vary from beat to beat and after provocative maneuvers but usually does not exceed grade 3.<br>
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| :❑ The murmur will increase with reduction in preload or afterload (Valsalva, standing, vasodilators), or with an augmentation of contractility (inotropic stimulation).<br>
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| :❑ The intensity of the [[murmur]] decrease with increase in [[preload]] (squatting, passive leg raising, volume administration) or [[afterload]] (squatting, vasopressors) or reduce [[contractility]] ([[β-adrenoreceptor blockers]]).<br>
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| :❑ [[LVH]] is present on the [[ECG]], and the diagnosis is confirmed by [[TTE]].<br>
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| :❑ [[MVP]] behaves similarly to that due to [[HOCM]] in response to the Valsalva maneuver and to standing/squatting, these two lesions can be distinguished by the presence of [[LVH]] in [[HOCM]] or a non ejection click in [[MVP]].<br>
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| ❑ Congenital [[pulmonic stenosis]]<br>
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| :❑ The [[mid-systolic]], crescendo-decrescendo [[murmur]] is best appreciated in the second and third left intercostal spaces.<br>
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| :❑ The duration of the [[murmur]] lengthens and the intensity of [[P2]] diminishes with increasing the degree of stenosis.<br>
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| :❑ An early ejection sound that decreases with [[inspiration]], and heard in younger patients.<br>
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| :❑ A parasternal lift and [[ECG]] evidence of [[right ventricular hypertrophy]] indicate severe pressure overload.<br>
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| :❑ [[TTE]] is recommended for complete characterization.<br>
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| ❑ [[ASD]] with left-to-right intra-cardiac shunting<br>
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| :❑ Grade 2–3 [[Heart murmur|mid-systolic murmur]] at the middle to upper left sternal border with fixed splitting of [[S2]].<br>
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| ❑ [[TTE]] is indicated to evaluate a grade 2 or 3 [[Heart murmur|mid-systolic murmur]] when there are other signs of [[cardiac disease]].<br>
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| ❑ An isolated grade 1 or 2 [[Heart murmur|mid-systolic murmur]], heard in the absence of symptoms or signs of [[heart disease]], is most often a benign finding for which no further evaluation.<br>|C07=<div style="float: left; text-align: left; width: 28em; padding:1em;">'''[[heart murmur|Late Systolic Murmurs]]'''<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
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| ❑ [[heart murmur|late systolic murmur]] that is best heard at the left ventricular apex is usually due to [[MVP]].<br>
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| ❑ The radiation of the [[murmur]] can help identify the specific mitral leaflet involved in the process of prolapse.<br>
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| ❑ With posterior leaflet prolapse, the [[murmur]] radiates to the base of the [[heart]].<br>
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| ❑ Anterior leaflet prolapse radiates to the axilla or left [[infrascapular region]].<br>
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| ❑ Standing causes the [[murmur]] to become louder and longer. With squatting the [[murmur]] becomes softer and shorter in duration.<br>
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| ❑ [[TTE]] is recommended for assessment of [[Heart murmur|late systolic murmurs]].<br>|C02=<div style="float: left; text-align: left; width: 28em; padding:1em;">'''[[Heart murmur|Early Diastolic Murmurs]]'''<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed"><BR> ❑ '''AR'''<br>
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| :❑ High pitched, blowing, decrescendo, early to [[Heart murmur|mid-diastolic murmur]], begins after the aortic component of [[S2]] (A2).<br>
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| :❑ Best heard at the second right interspace with the patient leaning forward at end [[expiration]].<br>
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| :❑ With primary valve disease, such as [[congenital bicuspid disease]], prolapse, or [[endocarditis]], the [[Heart murmur|diastolic murmur]] radiate along the left sternal border.<br>
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| :❑ When [[AR]] is caused by [[aortic root disease]], the [[Heart murmur|diastolic murmur]] may radiate along the right sternal border.<br>
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| :❑ The [[Heart murmur|diastolic murmur]] of [[acute,severe AR]] is notably shorter in duration and lower pitched than the murmur of [[chronic AR]].<br>
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| :❑ chronic [[severe AR]] is accompanied by several peripheral signs of significant diastolic run-off.<br>
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| ❑ '''[[Pulmonic regurgitation]]'''<br>
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| :❑ A decrescendo, early to [[Heart murmur|mid-diastolic murmur]] (Graham Steell murmur) that begins after the pulmonic component of [[S2]] (P2)<br>
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| :❑ Best heard at the second left interspace, and radiates along the left sternal border. The intensity of the [[murmur]] may increase with [[inspiration]].<BR>
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| :❑ [[PR]] is most commonly due to dilation of the valve annulus from chronic elevation of the [[pulmonary artery pressure]].<br>
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| :❑ To distinguish [[PR]] from [[AR]] as the cause of a decrescendo [[Heart murmur|diastolic murmur]] heard along the left sternal border, Signs of [[pulmonary hypertension]], including a [[right ventricular lift]] and a loud, single or narrowly split [[S2]], are present with [[PR]]<br>
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| :❑ [[PR]] in the absence of [[pulmonary hypertension]] can occur with [[endocarditis]] or a congenitally deformed valve, in this condition the [[Heart murmur|diastolic murmur]] is softer and lower pitched than the classic [[Graham Steell murmur]].<br>
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| ❑ [[TTE]] is indicated for the further evaluation of a patient with an early to [[Heart murmur|mid-diastolic murmur]].|C03=<div style="float: left; text-align: left; width: 28em; padding:1em;">'''[[Heart murmur|Mid-diastolic murmurs]]'''<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
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| ❑ '''[[MS]]'''<br>
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| :❑ The most common cause of [[MS]] is [[Rheumatic fever]], the [[murmur]] is low-pitched and is best heard with the bell of the stethoscope when the patient is turned in the left lateral decubitus position.<br>
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| :❑ Loudest at the left ventricular apex.<br>
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| :❑ It is usually of grade 1 or 2 intensity. The intensity of the [[murmur]] increases during maneuvers that increase [[cardiac output]] and [[mitral valve]] flow, such as [[exercise]]. An increase in the intensity of the [[murmur]] just before [[S1]], a phenomenon known as [[pre-systolic]] accentuation. Presystolic accentuation does not occur in patients with [[atrial fibrillation]].<br>
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| ❑ '''[[TS]]'''<br>
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| :❑ [[Murmur]] is best heard at the lower left sternal border and increases in intensity with [[inspiration]].<br>
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| :❑ A prolonged y descent may be visible in the [[jugular venous]] waveform.<br>
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| :❑ This murmur is very difficult to hear and often is obscured by left-sided acoustical events.<br>
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| ❑ '''Large [[left atrial myxomas]]'''<br>
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| :❑ The [[murmur]] associated with an atrial myxoma may change in duration and intensity with changes in body position. An [[opening snap]] is not present, and there is no pre-systolic accentuation.<br>
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| ❑ '''[[Austin Flint murmur]]'''
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| :❑ Due to chronic, [[severe AR]] is a low-pitched mid to late, grade 1 or 2 [[diastolic murmur]] at the apex.<br>
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| :❑ Distinguished from the [[murmur]] due to [[MS]] by the absence of an [[opening snap]] and the response of the [[murmur]] to a [[vasodilator]] challenge. Lowering [[afterload]] with an agent such as [[amyl nitrite]] will decrease the duration and magnitude of the [[Austin Flint murmur]]. The intensity of the [[diastolic murmur]] of [[mitral stenosis]] may either remain constant or increase with afterload reduction because of the reflex increase in [[cardiac output]] and [[mitral valve]] flow.
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| ❑ '''Severe, isolated [[TR]] and with large [[ASD]] and significant left-to-right shunting''' Other signs of an [[ASD]] are present including fixed splitting of [[S2]] and a mid-systolic murmur at the mid- to upper left sternal border.<br>
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| ❑ [[TTE]] is indicated for evaluation of a patient with a mid- to late [[diastolic murmur]].|C04=<div style="float: left; text-align: left; width: 28em; padding:1em;">'''[[Continuous murmur]]'''<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed"><br> ❑ Begin in systole, peak near the [[S2]], and continue into all or part of [[diastole]].<br>
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| ❑ If the [[heart murmur|continuous murmur]] heard at the upper left sternal border, mostly associated with a [[patent ductus arteriosus]].<br>
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| ❑ If the [[murmur]] heard at the upper right sternal border, it could be ruptured sinus of [[Valsalva aneurysm]].<BR>
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| ❑ A [[heart murmur|continuous murmur]] also may be audible along the left sternal border with a coronary arteriovenous fistula.<br>}}
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| {{Family tree/end}}
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| </small></small></small></small>
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| <br>
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|
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|
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| ===Strategy for evaluating heart murmurs===
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| <span style="font-size:85%">'''Abbreviations:''' '''ECG:[[electrocardiogram]] </span>
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| <small><small>
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| {{familytree/start |summary=PE diagnosis Algorithm.}}
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| {{familytree | | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | |B01=<div style="width:10em; text-align: center; padding:1em;">[[Cardiac murmur]]}}
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| {{familytree | | |,|-|-|-|-|-|-|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|.| | | | | | | | | | | |}}
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| {{familytree | | C01 | | | | | | | | | | | | C02 | | | | | | | | C03 | | | | | | | | | | |C01=<div style="width:10em; text-align: center; padding:1em;">[[Heart murmur|Systolic Murmur]]|C02=[[heart murmur|Diastolic Murmur]]|C03=<div style="width:10em; text-align: center; padding:1em;">[[heart murmur|Continuous Murmur]]}}
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| {{familytree | | |!| | | | | | | | | | | | | |!| | | | | | | | | |!| | | | | | | | | |}}
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| {{familytree | | |!| | | | | | | | | | | | | |!| | | | | | | | | |!| | | | | | | | | | | }}
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| {{familytree | | |!| | | | | | | | | | | | | |!| | | | | | | | | |!| | | | | | | | | | |}}
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| {{familytree | | |!| | | | | | | | | | | | | |!| | | | | | | | | |!| | | | | | | | | | |}}
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| {{familytree | |,|^|-|-|-|-|-|.| | | | | | | |!| | | | | | | | | |!| | | | | | | | | | |}}
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| {{familytree | D01 | | | | | D02 |-|-|-|-|-|-|(| | | | | | | | | |!| | | | | | | | | | |D01=<div style="width:10em; text-align: left; padding:1em;">❑ [[heart murmur|Midsystolic]],<br> grade 2 or less|D02=<div style="width:10em; text-align: left; padding:1em;">❑ [[heart murmur|Early systolic]],<br>❑ [[heart murmur|Midsystolic]] grade 3 or more,<br>❑ [[heart murmur|Late systolic]],<br>❑ [[heart murmur|Holosystolic murmur]]}}
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| {{familytree | |!| | | | | | | | | | | | | | |!| | | | | | | | | |!| | | | | | | | | | |}}
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| {{familytree |,|^|-|-|-|.| | | | | | | | | | |!| | | | | | | | | |)|-|-| D02 | | | | | |D02=<div style="width:10em; text-align: left; padding:1em;">❑ [[Venous hum]] <br> ❑ Mammary souffle of [[pregnancy]]}}
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| {{familytree | E01 | | E02 |-|-|-|-|.| | | | |!| | | | | | | | | |!| | | |!| | | | | | | |E01=Asymptomatic and no associated findings|E02=<div style="width:10em; text-align: left; padding:1em;">❑ Symptomatic or other signs of [[cardiac diseases]],<br>❑ If an [[ECG]] or [[X-ray]] has been obtained and is abnormal}}
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| {{familytree | |!| | | | | | | | | |!| | | | |!| | | | | | | | | |!| | | |!| | | | | | | | | |}}
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| {{familytree | E01 | | | | | | | | |!| | | | |!| | | | | | | | | |!| | | E02 | | | | | | | | | |E01=No further workup|E02=No further workup}}
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| {{familytree | | | | | | | | | | | |`|-|-|-| D01 |-|-|-|-|-|-|-|-|'| | | | | | | | | | |D01=<div style="width:20em; text-align: left; padding:1em;"> '''Echocardiography'''<br><div class="mw-collapsible mw-collapsed">Class I <br> ❑ [[Echocardiography]] is recommended for asymptomatic patients with [[heart murmur|diastolic murmurs]], [[heart murmur|continuous murmurs]], [[heart murmur|holosystolic murmurs]],[[heart murmur|late systolic murmur]], [[murmurs]] associated with [[ejection clicks]] or [[murmurs]] that radiate to the neck or back.(Level of Evidence: C) <br>
| |
| ❑ [[Echocardiography]] is recommended for patients with [[heart murmurs]] and symptoms or signs of [[heart failure]], [[myocardial ischemia/infarction]], [[syncope]], [[thromboembolism]], [[infective endocarditis]], or other clinical evidence of [[structural heart disease]].(Level of Evidence: C) <br>
| |
| ❑ [[Echocardiography]] is recommended for asymptomatic patients who have grade 3 or louder mid peaking [[heart murmur|systolic murmurs]].(Level of Evidence: C)<br> Class IIa <br>
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| ❑ [[Echocardiography]] can be useful for the evaluation of asymptomatic patients with [[murmurs]] associated with other abnormal cardiac physical findings or murmurs associated with an abnormal [[ECG]] or chest [[X-ray]].(Level of Evidence: C) <br>
| |
| ❑ [[Echocardiography]] can be useful for patients whose symptoms and/or signs are likely non cardiac in origin but in whom a cardiac basis cannot be excluded by standard evaluation.(Level of Evidence: C) <br> Class III <br>
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| ❑ [[Echocardiography]] is not recommended for patients who have a grade 2 or softer [[heart murmur|midsystolic murmur]] identified as innocent or functional by an experienced observer.(Level of Evidence: C)}}
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| {{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | | | f01 | | | | | | | | | | | | | | | | | | | | | | |f01=[[Catheterization]] and [[angiography]] if appropriate}}
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|
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| {{familytree/end}}
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| </small></small></small>
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|
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| ==Treatment==
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| The management of [[heart murmurs]] depend on the underlying cause. Click on each disease shown below to see a detail management for every cause of [[heart murmur]].<br>
| |
| <span style="font-size:85%">'''Abbreviations:''' '''HOCM:[[Hypertrophic cardiomyopathy]] </span>
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|
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|
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| {| class="wikitable" border="1"
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| !style="width: 300px;background:#4479BA"|{{fontcolor|#FFF| SYSTOLIC MURMUR}} !!style="width: 300px;background:#4479BA"|{{fontcolor|#FFF| DIASTOLIC MURMUR}}
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| |-
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| | ❑ '''[[Mitral regurgitation resident survival guide#Treatment of Acute Mitral Regurgitation|Acute Mitral Regurgitation]]''' <br> ❑ '''[[Mitral regurgitation resident survival guide#Treatment of chronic Mitral Regurgitation|chronic Mitral Regurgitation]]'''<br> ❑ '''[[Aortic stenosis resident survival guide#Treatment|Aortic stenosis]]'''<br> ❑ '''[[Hypertrophic cardiomyopathy resident survival guide#Treatment|HOCM]]'''<br>
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| | ❑ '''[[Aortic regurgitation resident survival guide#Treatment|Aortic regurgitation]]'''<br> ❑ '''[[Mitral stenosis resident survival guide#Treatment|Mitral stenosis]]'''<br>
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| |}
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|
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| ==Do's==
| |
| * Order [[echocardiography]] for asymptomatic patients with [[heart murmur|diastolic murmurs]], [[heart murmur|continuous murmurs]], [[heart murmur|holosystolic murmurs]], [[heart murmur|late systolic murmurs]],[[murmurs]] associated with [[ejection clicks]] or [[murmurs]] that radiate to the neck or back or [[murmurs]] and symptoms or signs of [[heart failure]], [[myocardial ischemia/infarction]], [[syncope]],[[thromboembolism]],[[infective endocarditis]].
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| * Order Cardiac [[Catheterization]] if there is a discrepancy between the [[echocardiographic]] and clinical findings.
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| * Do Serial measurements over time, or reassessment with a different imaging technology (radionuclide ventriculography or cardiac magnetic resonance) to determine surgical recommendations for asymptomatic patients with [[MR]] or [[AR]].
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|
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| ==Don'ts==
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| * Don't do [[Echocardiography]] for patients who have a grade 2 or softer [[heart murmur|midsystolic murmur]] identified as innocent or functional by an experienced observer.
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| * Don't re-place the [[cardiovascular]] examination by [[Echocardiography]].
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|
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| ==References==
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| {{Reflist|2}}
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|
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| [[Category:Resident survival guide]]
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