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ACTIVITY DISCLAIMER
Adult Heart Murmurs:
Musings of a Stethoscope
Eddie Needham, MD, FAAFP
The material presented here is being made available by the American
Academy of Family Physicians for educational purposes only. This material
is not intended to represent the only, nor necessarily best, methods or
procedures appropriate for the medical situations discussed. Rather, it is
intended to present an approach, view, statement, or opinion of the faculty,
which may be helpful to others who face similar situations.
The AAFP disclaims any and all liability for injury or other damages resulting
to any individual using this material and for all claims that might arise out of
the use of the techniques demonstrated therein by such individuals, whether
these claims shall be asserted by a physician or any other person. Every
effort has been made to ensure the accuracy of the data presented here.
Physicians may care to check specific details such as drug doses and
contraindications, etc., in standard sources prior to clinical application. This
material might contain recommendations/guidelines developed by other
organizations. Please note that although these guidelines might be
included, this does not necessarily imply the endorsement by the AAFP.
CME007 Friday, 9:15-10:15 a.m., Location: 147AB
CME008 Friday, 1:30-2:30 p.m., Location: 147AB
FACULTY DISCLOSURE
It is the policy of the AAFP that all individuals in a position to control
content disclose any relationships with commercial interests upon
nomination/invitation of participation. Disclosure documents are
reviewed for potential conflict of interest (COI), and if identified,
conflicts are resolved prior to confirmation of participation. Only those
participants who had no conflict of interest or who agreed to an
identified resolution process prior to their participation were involved
in this CME activity.
All faculty in a position to control content for this session have
indicated they have no relevant financial relationships to disclose.
The content of my material/presentation in this CME activity will not
include discussion of unapproved or investigational uses of products
or devices.
BiographyforEddieNeedham
• Practices“conceptiontoresurrection”family
medicine
• Taughtfamilymedicinefortwodecades
• Joyandpassiontoteachthewondersofthehuman
bodyandspirit.
• Marriedfor26yearswithfive(mostlygrown)
children
• Adventure:
• Rigorsoftriathlons,soccer,andvolleyball
• Wonderandsurpriseoffishing
• Mountaintopexperienceswithfriends
Learning Objectives
1.
Distinguish innocent and abnormal heart murmurs in patients and
classify them as systolic, diastolic or continuous.
2.
Formulate a differential diagnosis of specific cardiac sounds and
explain the pathology of heart murmurs to patients.
3.
Evaluate diagnostic factors in patients with suspected heart murmurs
using cost-effective cardiac testing.
4.
Coordinate referral and follow-up to a cardiologist for patients with a
pathologic cardiac examination, or who has cardiac symptoms and
questionable findings on the cardiac examination.
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Presentation Topics
•
•
•
•
Presentation Topics
Basic anatomy and cases
Heart sounds in Family Medicine
Auscultation demonstration
Subacute Bacterial Endocarditis prophylaxis
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•
•
•
•
Basic anatomy and cases
Heart sounds in Family Medicine
Auscultation demonstration
Subacute Bacterial Endocarditis prophylaxis
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Valvular Heart Disease (VHD)
• VHD contributes to more than 40,000
patient deaths and 100,000 operations
annually.
• Last update to ACC/AHA VHD guidelines
was 2008.
• VHD accounts for 10-20% of all cardiac
procedures in the United States.
Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated
into the ACC/AHA 2006 Guidelines for the management of patients with valvular
heart disease. J Am Coll Cardiol,. 2008; 52(13):e1-142
Creative commons license at: http://en.wikipedia.org/wiki/File:Diagram_of_the_human_heart_(cropped).svg
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Valvular Heart Disease (VHD)
Valvular Heart Disease (VHD)
• Pathologic murmurs requiring evaluation
– Any murmur in diastole
– Any murmur III/VI or louder
– Any murmur in late systole
– Murmurs that fall into diagnostic concern
• Hypertrophic cardiomyopathy (HCM/IHSS)
• A soft systolic murmur can still be concerning
– I/VI early diastolic murmur of aortic regurgitation
• The presence of symptoms in the medical
history helps determine the need for surgery
• Valvular stenosis obstructs forward flow
• Valvular regurgitation permits backward flow
• Aortic and mitral valves are most commonly
affected
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Cardiac Murmur
Systolic
Midsystolic
Grade 2 or less
Asymptomatic
and no
associated
findings
No further
evaluation
Symptomatic
or other signs
of cardiac
disease
Diastolic
Early systolic or
Midsystolic –
grade 3 or more;
Late systolic, or
Holosystolic
Continuous
Venous hum,
Mammary souffle
of pregnancy
Busy practice murmur algorithm
No further
evaluation
Get an Echo
Echocardiography
Cardiac catheterization and
angiography if appropriate
Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006
Guidelines for the management of patients with valvular heart disease. J Am Coll Cardiol,. 2008; 52(13):e1-142
Case 1
• Mr. Juniper is a 35 year old male with a 23/6 mid systolic murmur.
• He can run up to 3 miles but then feels
winded, no chest pain.
• He has a known bicuspid aortic valve.
• No evidence of LVH on EKG.
• What should we do?
35 year old male with bicuspid AV and
limited to 3 mile run - what to do?
•
•
•
•
Refer now for AV replacement
Repeat echo to check for progression
Trial of life --> Keep running
Vasodilator Rx to decrease afterload
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Case 2
Case 3
• 23 yo male of African descent with progressive
dyspnea.
• 27 yo male presents with near syncope with
exercise on bi-annual Army physical fitness
test
– Athletic build
– Easily discernable 3/6 mid to late systolic murmur
at left upper sternal border
– Louder with inspiration
– Palpable heave second left intercostal space
– ???
• Idiopathic pulmonary HTN with pulmonic
stenosis
27 yo male w/ near syncope, 2-3/6
mid to late sys murmur at LLSB,
softens w/ hand grip. What is the
murmur?
•
•
•
•
Severe aortic stenosis
Hypertrophic obstructive cardiomyopathy
Brugada syndrome
Mirtal regurgitation with MVP
Le Clinician existe toujours!
Strive to truly listen to the patient
– Very athletic build
– Easily discernable 2-3/6 mid to late systolic
murmur at left lower sternal border
– With hand grip, the murmur drops to 1/6
– With release of hand grip, the murmur is 3/6
before settling to 2-3/6
Technology
• In general, a transthoracic echocardiogram is
the first step in evaluating a new cardiac
murmur.
• Echo’s can also generate revenue for a busy
practice
• New/emerging technologies include:
– Real-time 3D echocardiography (MV pathology)
– Cardiac MRI (excellent general applications but
issues of access and expense limit use)
– Handheld echocardiography
Reality check 
Electronic stethoscope
GE VScan handheld ultrasound
Creative commons license at:
http://commons.wikimedia.org/wiki/File:Electronic_stethoscope.jpg
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Presentation Topics
•
•
•
•
Grading of murmurs
Basic anatomy and cases
Heart sounds in Family Medicine
Auscultation demonstration
Subacute Bacterial Endocarditis prophylaxis
•
•
•
•
Grade I/VI
Grade II/VI
Grade III/VI
Grade IV/VI
• Grade V/VI
• Grade VI/VI
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Barely discernable
Readily discernable
Loud and easily heard
Palpable thrill associated
with murmur (case)
Palpable with edge of
stethoscope on precordium
Heard with stethoscope off chest
(case)
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Auscultatory Excellence
Systolic Murmurs
Auscultatory Excellence
Diastolic Murmurs
Murmur
Aortic stenosis
Location
Quality
Crescendo2nd right ICS
decrescendo
Radiates to carotid
Harsh, medium pitch
Other findings
Delayed carotid upstroke
Soft A2 (late in course)
Paradoxical S2 splitting
Murmur
Aortic regurgitation
Quality
Decrescendo
High pitched blow
Location
Lower left sternal brdr
Leaning forward
Apex
Other findings
Wide pulse pressure
Other clinical findings
Quincke’s pulses ,etc…
Mitral regurgitation
Mid to late crescendo Apex
Holosystolic
Radiation to axilla
Medium to high pitch
S3
Midsystolic click with MVP
Mitral stenosis
Low pitched rumble
Crescendodecrescendo
Apex
Left lateral decubitus
Opening snap may be
present
Possible loud P2
Pulmonary stenosis
Crescendodecrescendo
Soft P2
Pulmonary regurgitation Decrescendo
2nd left ICS
Louder with inspiration
Tricuspid regurgitation
Holosystolic
Lower left sternal border Large v waves in jugular
Medium to high pitch Louder with inspiration
venous pulsations
Left sternal border
Louder with inspiration
2nd left ICS
Louder with inspiration
Tricuspid stenosis
Heart sounds common in FM
• Split S2 – physiologic vs fixed
• Split S2 vs S3
• S3 and S4
– volume and pressure overload respectively
• Aortic stenosis
• Mitral regurgitation
• Mitral valve prolapse
Low pitched rumble
Heart sounds not as common in FM
•
•
•
•
•
Aortic regurgitation
HCM
Ventricular septal defect (VSD)
Right-sided murmurs – vary with inspiration
Rare:
– Mitral stenosis with opening snap and middiastolic rumble
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Heart sounds
• Let’s draw a murmur
| <||||> |
S1 M
S2
• Systolic or Diastolic
• Early, mid, late, continuous
• Location:
•
URSB – Aortic valve
•
ULSB – Pulmonic valve
•
LLSB – Tricuspid … and aortic valves
•
Apex – Mitral … and aortic valves
Heart sounds
• Here’s what each sound looks like:
•
•
•
•
S1
|
|
|
S2
|
|
|
S1
|
|
|
S2
|
|
|
Heart sounds
•
•
•
•
•
•
Here’s the sound:
What does it look like?
S1
S2
S1
|
|
|
|
|
|
|
|
|
S2
|
|
|
Two conditions that vary with squat to
stand:
• MVP – Mitral valve prolapse
– When patient squats, click and MR murmur
move later in systole
– When patient stands up, click and MR murmur
move earlier in systole
• HCM – Hypertrophic cardiomyopathy
– When patient squats, murmur gets softer –
more blood in LV
– When patient stands, murmur gets louder –
less blood in LV
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It’s about the waves
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Common mistakes in auscultation
Now I’m here
• Minimize ambient noise
• Remove the patient’s shirt (hair?)
• Push firmly with the stethoscope
– If you left a ring on the skin, you pushed hard
enough
• Take the time to listen well
• Use provocative maneuvers (squat to
stand)
Anticipate the murmur
• Patient with BP 180/100 x 5 years
– Likely to have a thick LV
• Possible S4 – Pt with palpable S4
• Possible diastolic HF
• Patient with severe COPD, still smoking
– Possible pulmonary HTN, listen for:
• Fixed split S2, right sided murmurs that change with
respiration
• Patient with heart failure and an EF = 25%
– Likely to have mitral regurgitation murmur
Presentation Topics
•
•
•
•
Heart sounds demo
Basic anatomy and cases
Heart sounds in Family Medicine
Auscultation demonstration
Subacute Bacterial Endocarditis prophylaxis
• http://www.blaufuss.org/
• Heart Sounds demos
41
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Ausculation web sites - free
• http://www.wilkes.med.ucla.edu/inex.htm
– Auscultation Assistant
• http://depts.washington.edu/physdx/heart/demo.html
– University of Wash. Dept Med – heart sounds demo
• http://www.dundee.ac.uk/medther/Cardiology/hsmur.ht
ml
– University of Dundee for the Brits
• http://www.easyauscultation.com/heart-lung-soundsreference-guide.aspx
Presentation Topics
•
•
•
•
Basic anatomy and cases
Heart sounds in Family Medicine
Auscultation demonstration
Subacute Bacterial Endocarditis prophylaxis
44
Subacute Bacterial Endocarditis
Prophylaxis
A patient with MVP without mitral
regurgitation should receive SBE
prophylaxis?
• True
• False
46
Subacute Bacterial Endocarditis (SBE)
Prophylaxis – Which Patients
SBE
• Prophylaxis no longer indicated in
• ACC/AHA Guidelines changed significantly in 2008
• Clinical Indications (Who) for SBE prophylaxis
– Prosthetic valves and materials used to repair heart
valves: mechanical, biosynthetic, and homograft
– Prior history of infective endocarditis
– Unrepaired cyanotic congenital heart disease
– Repaired congenital heart defects within the first months
after repair
– Repaired congenital heart disease with residual defects
– Cardiac valvulopathy in a transplanted heart
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– MVP with or without murmur
– Bicuspid aortic valves
– GI/GU procedures, to include any
scope in any orifice doing any biopsy
Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update
incorporated into the ACC/AHA 2006 Guidelines for the management of
patients with valvular heart disease. J Am Coll Cardiol,. 2008; 52(13):e1-142
48
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SBE – Which Procedures
SBE – Which Drug
• Dental procedures that manipulate the gingiva or
periapical region of the teeth, or perforate the
oral mucosa
• Amoxicillin in non-PCN allergic patients
– 2 gm 30-60 minutes before procedure
– Cutting the gum  consider prophylaxis
• PCN allergy
• Respiratory tract procedures that break the
mucosal lining
• Procedures in patients with ongoing GI/GU
infections (possible enterococcus)
• Procedures on infected skin, skin structures, or
MSK tissue
• Surgery to replace heart valves, intravascular or
intracardiac procedures
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– Cephalexin (2 gm), azithromycin (500 mg),
clarithromycin (500 mg), or clindamycin (600 mg)
• Pts unable to take oral
– Ampicillin IV/IM (2 gm)
– PCN allergic
• Cefazolin or ceftriaxone (1 gm IV) or
clinda IV (600 mg)
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As the rippled
surface of a windkissed lake mirrors
the moon, so the
diaphragm of a
stethoscope
reveals the
chambers of a
heart
Practice Recommendations
• Appropriately grade murmurs (grade 1-6) to help
determine if murmur is physiologic or pathologic.
• Determine murmur characteristics: systolic vs diastolic,
timing, sound
• Clinically assess the cause of the murmur BEFORE
ordering the echo.
• Do not prescribe SBE prophylaxis for MVP with or without
MR
• Review internet auscultatory resources to improve clinical
skills
Contact
• [email protected]
• Office phone 407 646 7757
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