Cardiac Murmurs Valve disease Murmur character Best heard Pathology Symptoms Signs Causes (→ radiation) Systolic (radiate) Aortic stenosis Ejection systolic Upper RSE (→ carotids and Stops carotid outflow → Exertional dyspnoea Slow rising Senile calcification (most) (differentiate from MR by apex) Limited CO and LV hypertrophy Syncope Narrow pulse pressure Congenital CI = nitrates, ACEi separate S2) (coronary Heaving Bicuspid (e.g. Turners perfusion impaired) Soft or absent S2 (depending on AS severity) syndrome) May be LVF (S3, pulmonary oedema) Rheumatic Aortic sclerosis Ejection systolic Upper RSE (doesn’t radiate) Valve hard and inflexible → None No abnormal signs Senile calcification (most) Turbulence (thickening NOT narrowing) (differentiate from AS by normal pulse, apex → Local sound only and S2) Mitral regurgitation Pan-systolic Apex (→ left axilla) Regurgitation to left → Dyspnoea AF Papillary muscle dysfunction (post-MI) Left atrial dilation → LV dilation and Fatigue Displaced thrusting apex (volume overload) Dilated cardiomyopathy failure Soft S1 Rheumatic IF acute, LA pressure increases and LVF (S3, pulmonary oedema) Infective Expiration causes pulmonary oedema Pulmonary hypertension (RV heave, loud P2) Congenital Connective tissue disorders (e.g. Marfan’s) prolapse Mid-systolic click Apex (→ left axilla and back) In ventricular systole, a mitral valve Atypical Murmur only Associations: primary congenital, Marfan’s, and/or late systolic murmur leaflet prolapses to left atrium PKD, congenital disease, congestive (differentiate from MR by cardiomyopathy, HOCUM, myocarditis, normal S1 then gap before Ehlers-Danlos, osteogenesis imperfecta, murmur) SLE, muscular dystrophy Ventricular septal defect Pan-systolic Lower LSE (loud → whole During systole some from left Often none if small Loud P2 Congenital precordium) leaks into right ventricle Tricuspid regurgitation Pan-systolic Lower LSE Regurgitation to right atrium and Fatigue Giant V waves in JVP (giant JVP waves RV dilation in pulmonary hypertension

(differentiate from MR by systemic backflow Hepatic pain on exertion without RVF = TR) (most; e.g. due to chronic lung disease or seeing if louder on Ascites, oedema Pulsatile hepatomegaly left heart/valve disease) inspiration because it’s on Parasternal heave = severe Rheumatic the right + JVP + non- Infective endocarditis (IV drug user) piration displaced apex) Ebstein's anomaly (if split S1 and S2)

Ins (Pulmonary stenosis) Ejection systolic Upper LSE (→ back) Stops pulmonary outflow → RV Dyspnoea, fatigue, Dysmorphic face Congenital (most) hypertrophy oedema, ascites RV heave Diastolic (need to be accentuated) Mitral stenosis Low rumbling mid-diastolic Apex in left lateral position High left atrial pressure → Dyspnoea Malar flush (due to low cardiac output) Rheumatic with opening snap Pulmonary hypertension → Fatigue AF Others rare (e.g. congenital) RV hypertrophy → Haemoptysis Tapping apex (palpable S1) Tricuspid regurgitation → Chest pain Loud S1 Right heart failure (late) Pulmonary hypertension (RV heave, loud P2)

Aortic regurgitation Early diastolic Upper RSE or lower LSE sitting Systemic backflow Fatigue Collapsing pulse Acute causes (Sounds like a breath) forwards SOB Wide pulse pressure Infective endocarditis Palpitations Very displaced apex Aortic dissection Backflow signs: Chronic causes

Expiration -Corrigan’s (visible carotid pulsation) Connective tissue disorders (e.g. Marfan’s, -de Musset’s (head nodding pulse) ankylosing spondylitis) -Quinke’s (red colour pulsation in nails) Rheumatic ±Austin Flint murmur (apical diastolic rumble) Luetic heart disease (syphilis) Congenital Long standing hypertension (Tricuspid stenosis) Early diastolic Lower LSE Systemic congestion and R atrial dilation Fatigue, ascites, oedema Giant a wave and slow y descent in JVP Rheumatic (most), Congenital atresia, carcinoid (Pulmonary Decrescendo murmur in Upper LSE Pulmonary backflow Often none RV hypertrophy Any cause of pulmonary hypertension regurgitation) early diastole LV hypertrophy (e.g. due to stenosis on left side) = non-displaced heaving apex beat VS LV dilation = LVF (e.g. due to regurgitation on left side) = displaced thrusting apex beat © 2013 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision