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Heart Murmur, Emergency Medicine

Basics

Description

- Mitral stenosis: - Rheumatic heart disease - Rheumatologic disorders (systemic lupus erythematosus) - Calcification - Cardiac tumors (atrial myxoma) - Congenital - Prosthetic valve

- Mitral regurgitation, acute: - Endocarditis - Papillary muscle rupture or dysfunction - Rupture of chordae tendineae - Prosthetic valve

- Ventricular septal defect: - Congenital - Traumatic - Postinfarction

- Atrial septal defect: - Patent ductus arteriosus: - Congenital - Prematurity - Maternal-fetal rubella exposure

- Aortic stenosis: - Systolic crescendo-decrescendo murmur radiating to carotids - Carotid pulse described as parvus et tardus: Diminished intensity and late upstroke - Angina - Dyspnea on exertion - Exertional syncope

- Aortic regurgitation: - Diastolic blowing murmur at left sternal border - Pulmonary edema - Dyspnea - Tachycardia - Chest pain - Widened pulse pressure - Austin Flint murmur: Diastolic rumble from exposure of mitral valve to regurgitant flow - Corrigan pulse or water hammer pulse: Rapid upstroke and downstroke of the carotid pulse - Quincke pulse: Pulsations seen at nail beds - de Musset sign: Head bobbing with carotid pulse

- Mitral stenosis: - Diastolic, rumbling murmur at apex - Loud S1 with opening snap - Dyspnea - Orthopnea - Hemoptysis - Pulmonary edema - Emboli to systemic circulation - Atrial fibrillation

- Mitral regurgitation, chronic: - Holosystolic murmur at apex radiating to axilla - Dyspnea on exertion - Fatigue - Atrial fibrillation

- Tricuspid regurgitation: - Holosystolic, blowing murmur along left sternal border - Peripheral edema - Hepatosplenomegaly - Ascites - Atrial fibrillation - Large V wave in the jugular venous pulse

- Pulmonic stenosis: - Systolic crescendo-decrescendo ejection murmur at left upper sternal border - Severe lesions may have a thrill - Widely split S2 - Dyspnea with exertion in serious cases - May have signs of right heart failure

- Patent ductus arteriosus: - Continuous machinery murmur at upper left sternal border with systolic thrill - Cyanosis - Bounding peripheral pulses - Tachypnea

- Coarctation of the aorta: - Continuous or late systolic murmur - Possible aortic click related to bicuspid valve - Difference between upper and lower extremity pulses

- Hypertrophic cardiomyopathy/idiopathic hypertrophic subaortic stenosis: - Systolic, harsh, crescendo-decrescendo murmur at left sternal border - Increased intensity with Valsalva - Dyspnea - Chest pain - Exertional syncope - Sudden death

- Metoprolol (Lopressor): 5 mg IV q5-15 min for 3 doses, as tolerated - Nitroglycerin: - 10-20 μg/min IV - Titrate to effect - Max. 300 μg/min

- Nitroprusside: - 0.3 μg/kg/min IV - Titrate to effect - Max. 10 μg/kg/min - Protect bag from light - Thiocyanate toxicity from prolonged use

  • Sounds created by physiologic processes or functional and structural anomalies of the heart.
  • Stenotic lesions:Pressure overload in the chamber preceding the valve, leading to hypertrophy of the chamber in an attempt to overcome the increased resistance
  • Regurgitant lesions:Volume overload of the chamber preceding the valve, leading to chamber dilatation in an attempt to accommodate the regurgitant blood volume
  • Genetic abnormalities:Congenital defects associated with abnormal cardiac blood flow

Etiology

  • Aortic stenosis:Rheumatic heart diseaseCongenital bicuspid valveCalcificationProsthetic valve
  • Aortic regurgitation:Rheumatic heart diseaseEndocarditisAortic dissectionProsthetic valve
  • Mitral stenosis:Rheumatic heart diseaseRheumatologic disorders (systemic lupus erythematosus)CalcificationCardiac tumors (atrial myxoma)CongenitalProsthetic valve
  • Mitral regurgitation, acute:EndocarditisPapillary muscle rupture or dysfunctionRupture of chordae tendineaeProsthetic valve
  • Mitral regurgitation, chronic:Rheumatic heart diseaseMitral valve prolapseConnective tissue disease (Marfan syndrome)
  • Mitral valve prolapse:CongenitalConnective tissue disease
  • Tricuspid stenosis:
  • Tricuspid regurgitation:Rheumatic heart diseaseEndocarditisPulmonary HTN
  • Pericardial friction rub:PericarditisPericardial effusion
  • Ventricular septal defect:CongenitalTraumaticPostinfarction
  • Ventricular assist deviceImplantable pump supplements or replaces ventricular function
  • Pulmonic stenosis:CongenitalMaternal-fetal rubella exposureRheumatic heart disease
  • Pulmonic regurgitation:CongenitalRheumatic heart diseasePulmonary HTN
  • Atrial septal defect:
  • Patent ductus arteriosus:CongenitalPrematurityMaternal-fetal rubella exposure
  • Coarctation of the aorta:CongenitalTurner syndrome
  • Hypertrophic cardiomyopathy/idiopathic hypertrophic subaortic stenosis:CongenitalGenetic predisposition

Diagnosis

Signs and Symptoms

  • Aortic stenosis:Systolic crescendo-decrescendo murmur radiating to carotidsCarotid pulse described as parvus et tardus: Diminished intensity and late upstrokeAnginaDyspnea on exertionExertional syncope
  • Aortic regurgitation:Diastolic blowing murmur at left sternal borderPulmonary edemaDyspneaTachycardiaChest painWidened pulse pressureAustin Flint murmur: Diastolic rumble from exposure of mitral valve to regurgitant flowCorrigan pulse or water hammer pulse: Rapid upstroke and downstroke of the carotid pulseQuincke pulse: Pulsations seen at nail bedsde Musset sign: Head bobbing with carotid pulse
  • Mitral stenosis:Diastolic, rumbling murmur at apexLoud S1 with opening snapDyspneaOrthopneaHemoptysisPulmonary edemaEmboli to systemic circulationAtrial fibrillation
  • Mitral regurgitation, acute:Systolic, harsh, crescendo-decrescendo murmur at apexPulmonary edema
  • Mitral regurgitation, chronic:Holosystolic murmur at apex radiating to axillaDyspnea on exertionFatigueAtrial fibrillation
  • Mitral valve prolapse:Early to mid-systolic click often followed by systolic murmurPalpitationsChest pain
  • Tricuspid stenosis:Diastolic, high-pitched murmurPeripheral edemaHepatosplenomegalyAscitesFatigueAtrial fibrillationLarge A wave in the jugular venous pulse
  • Tricuspid regurgitation:Holosystolic, blowing murmur along left sternal borderPeripheral edemaHepatosplenomegalyAscitesAtrial fibrillationLarge V wave in the jugular venous pulse
  • Patent ductus arteriosus:Continuous machinery murmurCHF
  • Pericardial friction rub:Intermittent murmurSystolic and/or diastolic component
  • Ventricular septal defect:Harsh, holosystolic murmur loudest along lower left sternal border
  • Ventricular assist device:Mechanical hum at apexContinuous or pulsatileMay have adequate perfusion without palpable pulse or measurable BP
  • Pulmonic stenosis:Systolic crescendo-decrescendo ejection murmur at left upper sternal borderSevere lesions may have a thrillWidely split S2Dyspnea with exertion in serious casesMay have signs of right heart failure
  • Pulmonic regurgitation:High-pitched, early, decrescendo diastolic murmurWidely split S2Associated with Graham Steell murmur of pulmonary HTN (high-pitched early diastolic murmur)May have signs of right heart failure
  • Atrial septal defect:Systolic ejection murmur in secundum defectSecundum associated with pulmonary HTNWide fixed S2No murmur in PFO
  • Patent ductus arteriosus:Continuous machinery murmur at upper left sternal border with systolic thrillCyanosisBounding peripheral pulsesTachypnea
  • Coarctation of the aorta:Continuous or late systolic murmurPossible aortic click related to bicuspid valveDifference between upper and lower extremity pulses
  • Hypertrophic cardiomyopathy/idiopathic hypertrophic subaortic stenosis:Systolic, harsh, crescendo-decrescendo murmur at left sternal borderIncreased intensity with ValsalvaDyspneaChest painExertional syncopeSudden death

Physical Exam

  • Auscultation of heart and lung sounds
  • Evaluation of pulses, peripheral perfusion, and edema

Essential Workup

For more details, see Valvular Heart Disease, Mitral Valve Prolapse, Congenital Heart Disease, Patent Ductus Arteriosus, Pericarditis, and Pericardial Effusion/Tamponade.

Diagnosis Tests & Interpretation

Imaging

  • EKG
  • CXR
  • Echo:Evaluate valves, chambers, flow
  • CT:Rule out aortic dissection

Diagnostic Procedures/Surgery

Acute regurgitant lesions: Cardiac catheterization

Differential Diagnosis

See Etiology.

Treatment

Pre-Hospital

  • IV fluids:Patients with critical aortic stenosis are very sensitive to fluid shifts.
  • Oxygen as appropriate

Initial Stabilization/Therapy

  • Oxygen
  • IV access
  • Cardiac monitor
  • Treat symptoms (CHF, dysrhythmias)
  • Exercise care with fluids and medications in aortic stenosis

Ed Treatment/Procedures

For more details, see Endocarditis, Valvular Heart Disease, Mitral Valve Prolapse, Congenital Heart Disease, Patent Ductus Arteriosus, Pericarditis, and Pericardial Effusion/Tamponade.

Medication

  • Digoxin: 0.5 mg IV, then 0.25 mg IV 6 and 12 hr later
  • Diltiazem (Cardizem):0.25 mg/kg (17.5 mg for 70 kg person) IV over 2 minMay rebolus after 15 min with 0.35 mg/kg IVStart drip at 5-15 mg/hr
  • Furosemide (Lasix):20-80 mg IV; may increase dose if necessaryMax. of 600 mg per 24 hr
  • Heparin:80 U/kg bolus IV, then drip at 18 U/kg/hrMonitor partial thromboplastin time
  • Metoprolol (Lopressor): 5 mg IV q5-15 min for 3 doses, as tolerated
  • Nitroglycerin:10-20 μg/min IVTitrate to effectMax. 300 μg/min
  • Nitroprusside:0.3 μg/kg/min IVTitrate to effectMax. 10 μg/kg/minProtect bag from lightThiocyanate toxicity from prolonged use
  • Propranolol (Inderal):1-3 mg IV q2-5min up to max 5 mgNo additional doses for 4 hrs after reaching max dose or desired response

Follow-Up

Disposition

Admission Criteria

  • Signs of cardiac ischemia
  • Syncope or near syncope
  • Pulmonary edema
  • Hemodynamic instability
  • Endocarditis
  • Arrhythmia

Discharge Criteria

  • Asymptomatic
  • Hemodynamically stable

Issues for Referral

Patients with new murmurs should be referred to their caregiver or a cardiologist.

Follow-Up Recommendations

  • Patients should always inform their medical and dental caregivers that they have a heart murmur.
  • To avoid an infection of the lining of the heart, antibiotics may be needed before procedures such as teeth cleaning.

Pearls and Pitfalls

Patients with new heart murmurs and fever need to be assessed for endocarditis.

Additional Reading

  • Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. Circulation. 2006;114:e84-e231.
  • Frank JE, Jacobe KM. Evaluation and management of heart murmurs in children. Am Fam Physician. 2011;84:793-800.
  • Nishimura RA, Carabello BA, Faxon DP, et al. ACC/AHA 2008 Guideline update on valvular heart disease: Focused update on infective endocarditis. Circulation. 2008;118:887-896.
  • www.blaufuss.org/tutorial/
  • www.easyauscultation.com/heart-sounds.aspx

Codes

ICD9

  • 394.0 Mitral stenosis
  • 424.1 Aortic valve disorders
  • 785.2 Undiagnosed cardiac murmurs
  • 996.02 Mechanical complication due to heart valve prosthesis
  • 395.9 Other and unspecified rheumatic aortic diseases
  • 424.0 Mitral valve disorders
  • 746.4 Congenital insufficiency of aortic valve

ICD10

  • I05.0 Rheumatic mitral stenosis
  • I35.0 Nonrheumatic aortic (valve) stenosis
  • R01.1 Cardiac murmur, unspecified
  • T82.09XA Mech compl of heart valve prosthesis, initial encounter
  • I06.8 Other rheumatic aortic valve diseases
  • I34.0 Nonrheumatic mitral (valve) insufficiency
  • I34.1 Nonrheumatic mitral (valve) prolapse
  • I35.1 Nonrheumatic aortic (valve) insufficiency
  • Q23.1 Congenital insufficiency of aortic valve

SNOMED

  • 88610006 Heart murmur (finding)
  • 60573004 Aortic valve stenosis (disorder)
  • 86466006 Rheumatic mitral stenosis (disorder)
  • 250974001 Prosthetic aortic valve regurgitation (disorder)
  • 12023003 Rheumatic disease of aortic valve
  • 409712001 mitral valve prolapse (disorder)
  • 48724000 Mitral valve regurgitation (disorder)
  • 60234000 Aortic valve regurgitation (disorder)
  • 72352009 bicuspid aortic valve (disorder)