Cardiovascular examination quiz Part 2

If originating from the LV, the 4th heart sound is best heard over apex with patient in the left lateral position and is softer during inspiration. When originating from the RV it is best heard over left lower sternal border and is louder during inspiration. Although higher pitched than a 3rd heart sound, it is still best heard with the bell of the stethoscope. (link)

A VSD causes a 3rd heart sound. Acute mitral regurgitation can cause a 4th heart sound, but chronic MR causes a 3rd heart sound, Aortic stenosis, pulmonary stenosis and pulmonary hypertension can also cause a 4th heart sound.(link)

Ejection clicks are the most common early systolic sounds and are due to abrupt halting of the semilunar valves. An aortic ejection click is a loud high frequency sound associated with aortic stenosis due to a bicuspid aortic valve, but not usually with calcific aortic stenosis. It does not vary with respiration and is best heard at the apex. An opening snap is a high pitched early diastolic sound associated with mitral stenosis. It is best heard between the apex and the left lower sternal border with the patient in the left lateral position and is softer in inspiration. (link)

A Grade 1 murmur is just audible with a good stethoscope in a quiet room. Grade 2 is soft but readily audible with a stethoscope. Grade 3 is easily heard with a stethoscope. Grade 4 is an obvious murmur with a palpable thrill. Grade 5 is very loud, heard not only over the precordium but elsewhere in the body. Grade 6 can be heard with the stethoscope off the chest ( i.e. just possibly audible with a stethoscope in a busy ED!). (link)

Papillary muscle dysfunction usually causes a late systolic murmur. (link)

The murmur of a PDA is usually continuous, not just systolic. (link)

Isometric exercise reduces the murmur of aortic stenosis, HOCM and mitral valve prolapse. (link)

AS is the most common isolated valve lesion. (link)

The most common cause of isolated aortic valve disease in younger people in Australia is aortic stenosis. The most common cause of AS in this population is a congenital bicuspid valve, which accounts for about 60% of cases. It has a 1 – 2% prevalence in the general population, is more common in males and is associated with aortic dissection. Degenerative calcific aortic tricuspid valve is the next most common in this age group (and most common in people > 70 years of age, and increasing in frequency as the population ages). Rheumatic heart disease is the third most common cause (and decreasing in frequency), is associated with AR and nearly all cases also have mitral valve disease. Coarctation of the aorta is the least likely cause. (link)

A slow upstroke or plateau pulse has a LR + of 8.
BP changes are unreliable in the elderly so the pulse pressure may be normal or minimally reduced even in severe AS.
a prominent a wave and RVF due to septal hypertrophy (Berheim effect) can be caused by AS, however other causes of a prominent a wave (e.g. TR) make this a less specific sign. A soft H2 has a LR+ for AS of 3.1 and is less specific than a slow upstroke or plateau. (link)

The murmur of AS may be soft in severe disease due to LV dysfunction. Radiation of the murmur to the neck is not considered a sign of more severe AS. (link)

Aortic sclerosis is at least as common as aortic stenosis in older patients and has a systolic murmur similar to aortic stenosis, except that it peaks in early, rather than late, systole. There is no reduction in pulse pressure, the pulse volume and form is normal and there is no single or reversely split H2 as can occur in aortic stenosis. Radiation to the neck can occur in either aortic sclerosis or stenosis.(link)

Duroziez’s sign is systolic and diastolic murmurs over the partly occluded femorals. A water hammer pulse is another peripheral sign of AR. (link)

Another common cause is a bicuspid aortic valve and hypertension in older people. Other uncommon causes include aortic dissection, Marfan’s syndrome, VSD and tertiary syphilis. (link)

Examination is about 75% sensitive and 90% specific – so if you hear the typical murmur, the patient very likely has AR. Examination is only 25% sensitive for mild AR as the early diastolic murmur may not be heard unless the patient is sat up and auscultation occurs in full expiration.(link)