Murmur
- How to describe it
- What to look for
- What to ask
- What to do
Where to listen
- Aortic valve
- Pulmonic
- Erbs point (3rdintercostal space, left paraseternal)
- Tricuspid
- Apical
Describing a murmur
- Systolic vs. diastolic
- Where is it loudest?
- Does it radiate elsewhere?
o Carotids
o Apex
o Everywhere
What to look for?
- BP
o Hypertensive vs. hypotensive
o Narrow or wide pulse pressure (normal is 30-50mmHg)
- Radial pulse
o Sinus rhythm vs. atrial fibrillation
o Slow rising
o Collapsing
- Heart failure
o Left heart failure
o Right heart failure
o Congestive heart failure
What to ask
- Cardiac symptoms, e.g. SOB, CP, orthopnoea or PND?
- Physical capacity, ?change
- Hx of rheumatic fever
- Hx of congenital heart disease
Why is symptom so important?
- Management of valvular heart disease differs greatly depending on the presence or absence of symptoms.
- In aortic stenosis, prognosis drastically deteriorates, calling for aortic valve intervention.
Natural of history of aortic stenosis - all depends on symptoms! (uptodate.com)
Tips
- Time your murmur, systolic vs diastolic
- Inspiration accentuates right sided murmurs
- Expiration accentuates left sided murmrus
- AR is best heard sitting forward in expiration
- Use bell of stethoscope to listen for MS, low pitched murmur
- Duration not loudness of murmur usually correlates with severity
- Young and slim person with pectus deformity and AR – think of Marfans
- Management of valvular disease is primarily driven by symptoms
Author: Dr Gary Lau