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Murmurs and Cardiac Disease

Murmurs and Cardiac Disease. Anthony Liu , MD. Factoids. 61% of murmurs referred to sub-specialist are innocent murmurs Study (June 2000) on pediatric residents at Duke found their diagnostic accuracy = 33%. Red Flags!. Feeding intolerance, FTT, respiratory distress or cyanosis

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Murmurs and Cardiac Disease

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  1. Murmurs and Cardiac Disease Anthony Liu, MD

  2. Factoids • 61% of murmurs referred to sub-specialist are innocent murmurs • Study (June 2000) on pediatric residents at Duke found their diagnostic accuracy = 33%

  3. Red Flags! • Feeding intolerance, FTT, respiratory distress or cyanosis • Older children: chest pain esp. with exercise, syncope, exercise intolerance or family h/o sudden death • Family h/o Marfans • Aortic aneurysm, AR, MR • Downs Syndrome • Endocardial cushion defect, VSD • DiGeorge • Interrupted aortic arch, truncus arteriosus • Noonan • PS secondary to dysplastic pulm. valve

  4. Red Flags! • Increased precordial activity • Decreased femoral pulses • Abnormal S2 • Clicks • Loud or harsh murmur • Increased intensity of murmur when standing

  5. Cardiac Physical Exam • Precordial palpation • Increased precordial activity: • Increased ventricular stroke volume • Occurs with ASD, large VSD or significant PDA • Stress, anemia and hyperthyroidism • Palpate pulses • Brachial and femoral to rule out coarctation

  6. Cardiac Physical Exam- Auscultation • S1 • Closure of the AV valves • Clicks- Asynchronous closure of the mitral and tricuspid valves • Aortic Stenosis • Ejection clicks from the aortic valve heard at apex and do not vary with respiration • Midsystolic Click • Mitral prolapse

  7. Cardiac Physical Exam- Auscultation • S2: • Closure of the aortic and pulmonic valves • Physiological splitting- normal split S2 with inspiration • Delayed closure of the pulmonic valve because inspiration brings more blood into the right ventricle, prolonging RV ejection • Loud single S2 • Pulmonary hypertension • Semilunar valves dysfunction

  8. Murmurs • Systolic vs. Diastolic • Systolic murmurs: usually result of blood flow across an outflow tract, VSD, or PDA • Intensity: • Grade 1 – you can’t hear it • Grade 2 – soft but easily heard, you think you hear it • Grade 3 – loud, you know you hear it • Grade 4 - +Thrill • Grade 5 - Thrill and heard with side of bell • Grade 6 - audible without stethoscope • ≥ Grade 4 = Pathologic

  9. Murmur Attributes • Timing: early, middle or late systole, holosystolic, diastolic? • Tone/Pitch: harsh, blowing, musical/vibratory • Location: highest intensity • Changes with position: most pathologic murmurs will not change much with standing

  10. That’s All Folks!

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