dynamic auscultation of heart sounds and murmurs · 08 presentation to take care health system for...
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Dynamic Auscultation ofHeart Sounds and Murmurs
W. Lane Edwards, Jr., MSN, ARNP, ANPHospitalist Group of Southwest Florida
Affiliate Professor of Nursing, University of Alaska at Anchorage
AcknowledgementThe sounds you hear today are
complements of “Listening to the Heart” by Daniel Mason, MD., Professor of Medicine, Drexel University College of MedicineUniversity College of Medicine, Hahnemann University Hospital, Philadelphia, Pa.
Copyright release 10-9-08 to Partners in Healthcare Education, LLC for 10-18-08 Presentation to Take Care Health System for internal use only.
DisclosuresReal or Potential Conflicts of Interest
W. Lane Edwards, Jr., MSN, ARNP,ANPRecipient of Grant/Research Support
Roche, GSK, Merck, AZ, Novartis, Proctor and Gamble, Pfizer
Speakers BureauMerck, Takeda, AstraZeneca, Novartis, Roche, Novartis, Pfizer
Major Stock/ShareholderNone
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Where are we?
Differentiate Mitral Regurgitation from Aortic Stenosis?Differentiate Systolic from Diastolic
©Edwards 2008
Differentiate Systolic from Diastolic Murmurs?Differentiate S3 from S4?Recognize a stethoscope 4 out of 5 trys?
Physiologic ApproachKey to Understanding the creation of “noise” within the cardiovascular system is based on
©Edwards 2008
is based on What causes that noise
S4 – atrial contractionSignificant aid in retention of sounds.
I repeat myself………Some say it is a sign of aging.Some say that I just ramble.Some attribute it to SDAT in my f lfamily
My excuse is a learning theory that says repetition strengthens learning, that’s my story, and I am sticking with it.
Heart Sounds and MurmursObjectives
Describe a murmur by timing, radiation, characteristics, and point of intensityGrade a murmur by its auscultatory
©Edwards 2008
Grade a murmur by its auscultatory characteristicsDifferentiate systolic from diastolic murmurs by clinical presentation
Objectives …..Distinguish split heart sounds from S3 & S4 by characteristics and timingDifferentiate first and second heart
©Edwards 2008
Differentiate first and second heart sounds by characteristics and location of soundsProvide the physiologic rationale for creation of the 3rd & 4th heart sounds.
Objectives…...Identify the clinical presentation of selected lesions of the aortic and mitral valves
©Edwards 2008
valvesDiscuss the medical and surgical treatment for each valve lesion.
Today’s AgendaAnatomyCirculationCreation of Heart
First Heart SoundSecond Heart Sound
-Split Sounds
©Edwards 2008
Creation of Heart SoundsThe Cardiac CycleAnticipation !Ascultatory Positions
Third Heart SoundFourth Heart SoundSummation Gallop
Part II - The MurmursDescription of MurmursCharacteristics
Aortic StenosisAortic InsufficiencyMitral Insufficiency
©Edwards 2008
HolosystolicDecrescendoCrescendo
Grading of Murmurs
Mitral InsufficiencyMitral StenosisProsthetic Valves
Circulation Review
©Edwards 2008
Types of ValvesPressure
Aortic & PulmonicDependent onDependent on pressure gradients
Structural Support Mechanisms
Mitral & TricuspidCordae and papillary muscles
Right Atrium and Tricuspid Valve
Unidirectional blood flow from RA to RVRt. Atria ExpansionRt. Atrial Mixing
different O2 satsTricuspid Valve
low pressuresmall supportstructures
Low pressure gradient
Tricuspid Valve
Pulmonic Valve•Unidirectional blood
flow from RV to PulmonaryPulmonary circuit
•Pressure valve•No structural support•Moderate pressure gradient
Pulmonic Valve
Left Atrium and Mitral Valve
Lt Atria Fixed SizeMitral Valve
more cordaemore cordaestronger papillary
musclespart of inferior wallInferior MI issuesPressure issuesNo Valves to Lungs
Mitral Valve
Mitral Valve Open and Closed
Aortic Valve
Normal vs Bicuspid Aortic Valve
Aortic Cusps
Systolic - Diastolic
The Cardiac
©Edwards 2008
The CardiacCycle
©Edwards 2008
Rapid LV FillingMitral Valve OpensBlood stored in prior cycle rushes into left ventricle.If Preload high
S3
DiastosisAs the Mitral Valve is open, blood continues to fill from h hthe LA to the LV
increasing pressure and wall tension
Atrial ContractionFollowing the P wave of the EKG, the atria contract augmenting anotheraugmenting another 20-30% volume increase in LVIf large preload
S4
Both Doors Closed ….When pressure in Lt Ventricle exceeds that of the LA, the
l l lmitral valve closesAortic Valve is closedRoom get smaller!Pressure goes up
Aortic EjectionWith the Mitral valve prevented from opening by chordae
d lland papillary musclesAortic valve set by pressure above the valvePressure in LV increases
Aortic Valve OpensWith pressure below the valve higher than above the
l hvalve, the aortic valve opensWhen ventricle empties and the pressure is less in LV, aortic valve cusps fill with blood and close
What if….Mitral valve can’t open adequatelyMitral Valve can’t close during systoleAortic valve can’t open wellAortic valve can’t close well
Anticipation of Abnormals
Rhythm Disturbances - Conduction Abnormalities
Atrial Fibrillation - Atrial Flutter
©Edwards 2008
Atrial Fibrillation Atrial FlutterAtrio-ventricular ids-associationPacemaker rhythmsBundle Branch Blocks
Intraventricular Conduction Delays
Anticipation of Abnormals
History of Hypertension
©Edwards 2008
Mitral RegurgitationS3S4
Anticipation of Abnormals
Congestive Heart Failure
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Mitral RegurgitationS3S4
Anticipation of Abnormals
Volume / Pressure Overloads
©Edwards 2008
Splitting of Heart SoundsS3S4
Anticipation of Abnormals
Valvular Abnormalities
©Edwards 2008
Ejection Sounds, ClicksOpening SnapsKnocks, plopps
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The tool…
Listening to The Heart. Daniel Mason, MD. Second Edition. FA Davis. 2000
Apical
Left Lower
Aortic
Pulmonic
Anatomical Auscultation Points
Left Lateral Sternal BorderRt. Heart and triscuspid valve4th ICS, Left Sternal Border
©Edwards 2008
4th ICS, Left Sternal BorderApex
Lt. Heart or Mitral area5th intercostal space, mid clavicular line
Anatomical Auscultation Points
Base LeftPulmonic Area2nd ICS, Left of Sternum
©Edwards 2008
2nd ICS, Left of SternumMitral & Aortic Sounds also heard
Base RightAortic Area2nd ICS, Right of Sternum
Normal First Heart Sound
Closure Mitral -Tricuspid ValvesOccurs with onset of
©Edwards 2008
Occurs with onset of the apical pulse and carotid pulsationHeard loudest at the apex and LLSB with diaphram (high)
Normal S2Closure of Aortic & Pulmonic ValvesS1 longer & lower
©Edwards 2008
gS2 is shorter & sharperAortic 1st; A2P2Base Of Heart with diaphram (high)
Listen
Splitting of S2p gNormal Split
Physiological SplitParadoxical Split
Closing OrderLeft Ventricle
Normal (physiological)Aortic –Pulmonic A2-P2
Abnormal (paradoxical)Pulmonic Aortic P2 A2
Normal Split S 2Splitting during inspiration is normalExpiration the
©Edwards 2008
splitting will do awayIncreased blood intake into Rt. Heart during inspiration
Listen
Paradoxical Split S 2Abnormally Wide Split S 2
Heard split in inspiration and expiration
©Edwards 2008
Best heard base Lt. with diaphramRBBB, LBBBPulmonary Stenosis
Paradoxical
Fixed
Listen
S 3Opening of Mitral Valve - rush inVentricular Overload
Myocarditis
©Edwards 2008
MyocarditisCHF, Tachy’s
Bell over Apex - Lt. Lateral RecumbentPhysiologic in young <30 (!)
S 3
S 3
Listen
Fourth Heart Sound S4
Caused by Atrial ContractionIncreased LV Stiff
©Edwards 2008
Primary Myo DzHtnCADAortic PulmonaryStenosis
Bell at Apex
S4
Listen
Listen
Normal vs Bicuspid Aortic Valve
Listen
©Edwards 2008
Describing a MurmurTiming - Systolic Vs DiastolicIdentify area heard loudestIdentify radiation of sound
©Edwards 2008
Identify radiation of soundIdentify Duration and Characteristics
Grading of MurmursGrade I
very faint - takes several cycles to hear
©Edwards 2008
hear
Grade IIquiet, but heard immediately, firstcycle
Grading of MurmursGrade III
Moderately loud, but without thrill
©Edwards 2008
Grade IVloud, may be associated with a thrill
Grading of MurmursGrade V
very loud,may be heard with a stethoscope partly off the chest,
©Edwards 2008
stethoscope partly off the chest, usually associated with a thrill
Grade VIHeard with stethoscope off the chesthas a thrill
Listen
Systolic
Diastolic
The Misconception
©Edwards 2008
Mitral Regurgitation
l S
Electrocardiogram
Mitral Stenosis
Aortic Stenosis
Aortic Insufficiency
When Do I get an echo?New discovery of murmurChange in clinical presentationAnnually for grade 3 or above murmursAnnually for grade 3 or above murmursChange in LV function
Listening for Aortic Stenosis
Aortic Stenosis
Aortic Valve Vegetations
Aortic Stenosis
Pathophysiology AS
Clinical – low output state
Aortic Stenosis
Aortic StenosisLow forward flow
Dizzinessfatiguefatigue
LV geometry changesFibrillation possible
LA pressure upPulmonary back pressure
Listen
Afterload reductionPreload reductionPVR
Treatment of AS
PVRIncreased Intravascular VolumeAnti platelet
AorticAorticInsufficiency
AorticffInsufficiency
Aortic Insufficiency Compromised diastolic filling of coronary arteriescoronary arteriesIABPcontraindicatedEnhanced preload – LVLVH as compensation
Aortic Insufficiency
Aortic Insufficiency
Listen
Afterload reductionPreload reductionPVR
Treatment of AI
PVRIncreased Intravascular VolumeAnti platelet
MitralMitral Insufficiency
Listening
Mitral Insufficiency
Acute
Cordal Rupture
Chronic
Increasing LV
Mitral Insufficiency
Cordal RuptureInferior wall MIPapillary Muscle RuptureVegetations on leaflet
Increasing LV geometry changesIncreasing MR
Large LAHigh Pulmonary PressureReflection to Lungs
Mitral Insufficiency
Reflection to LungsLVHRt. Heart Failure
Primary clinical –Respiratory complaints
Listening to The Heart. Daniel Mason, MD. Second Edition. FA Davis. 2000
Listen
Afterload reductionPreload reductionPVR
Treatment of MI
PVRIncreased Intravascular VolumeAnti platelet
Listening to MS
Normal Mitral Valves
Mitral Stenosis
Mitral Stenosis
Thrombus Left Atria
Listening to The Heart. Daniel Mason, MD. Second Edition. FA Davis. 2000
Mitral StenosisHuge Left AtriaMural ThrombusArrhythmia controlLow forward flow
Right heart failureMinimal LV geometry changesMostly Pulmonary with some decreased flow
Listen
Afterload reductionPreload reductionPVR
Treatment of MS
PVRIncreased Intravascular VolumeAnti platelet
Left Atrial Mixoma
Listen
Prosthetic ValvesProsthetic Valves
Tissue Valves
Starr-Edwards Caged Ball
Ball Cage
©Edwards 2006
gValves
Ball Cage Valve
Bjork Shiley Tilting Disc
©Edwards 2006
St Jude Valve
St Jude Valve
St Jude Valve
Just wantedT it
©Edwards 2008
To say itFormally!
For Listening