CVS valves

• The S1 or “lub” heart sound is from the closure of the mitral (M1) and tricuspid (T1) valves
• The S2 heart sound is from the closure of the aortic (A2) and pulmonary (P2) valves
• S3 and S4 are abnormal additional heart sounds caused by heart failure
• Intensity of heart sounds or murmurs is graded using the Levine scale
• Levine intensity scale

  I = lowest intensity - hard for even an expert to hear
• Levine intensity scale

  II = low intensity - usually audible to all listeners
• Levine intensity scale

  III = medium intensity - easy to hear but no palpable thrill
• Levine intensity scale

  IV = medium intensity but with palpable thrill
• Levine intensity scale

  V = loud with palpable thrill
• Levine intensity scale

  VI = loudest - palpable thrill and murmur can be heard with stethoscope raised above chest
• A systolic murmur occurs on or after S1. Finishes before or on S2.
• A diastolic murmur starts on or after S2. Ends on or before S1.
• The 3 types of systolic murmurs:

  1. Midsystolic/systolic ejection murmurs
  2. Pansystolic murmurs
  3. Late systolic murmurs
• The two midsystolic murmurs are aortic stenosis and pulmonary stenosis
• The main causes of aortic stenosis are senile calcification, congenital and rheumatic
• Aortic Stenosis should be suspected in any elderly patient that presents with chest pain, exertional dyspnoea and syncope
• The classic triad for aortic stenosis is angina, syncope and heart failure
• Aortic stenosis can be auscultated over the right 2nd ICS

  Will be heard as a high pitched crescendo-decrescendo systolic murmur

  Murmur radiates to the carotid arteries
• ECG findings for AS include P-mitrale, LVH, LAD and LBBB
• AS can present on CXR as LVH and a calcified aortic valve
• If AS is symptomatic, the prognosis is poor without prompt valve replacement
• 95% of cases of pulmonary stenosis have a congenital cause. Other causes are rheumatic fever and carcinoid syndrome.
• Pulmonary stenosis can cause dyspnoea, fatigue, oedema and ascites
• Pulmonary stenosis causes a prominent A wave in the JVP
• Pulmonary stenosis causes a high pitched mid-systolic murmur.

  It can be auscultated over the left 2nd ICS.

  The murmur radiates to the left shoulder.

  Murmur intensity increases on inspiration.
• ECG findings for pulmonary stenosis include RVH, RAD and RBBB
• In pulmonary stenosis prominent pulmonary arteries can be seen on a CXR.
• For pulmonary stenosis, diagnosis is sought via cardiac catheterisation
• The two types of pansystolic murmur are mitral regurgitation and tricuspid regurgitation
• Causes of mitral regurgitation include: LV dilation, annular calcification, rheumatic fever, infective endocarditis, mitral valve prolapse and connective tissue disorders.
• Patients with mitral regurgitation typically present with dyspnoea, fatigue, palpitations and infective endocarditis
• Mitral regurgitation causes a displaced, hyperdynamic apex
• Mitral regurgitation causes a high pitched systolic murmur that can be heard over the apex but radiates to the axilla
• A common ECG finding in mitral regurgitation is atrial fibrillation and LVH
• CXR findings in mitral regurgitation include large left atrium and ventricles, mitral valve calcification and pulmonary oedema
• Management of mitral regurgitation:

  important to control rate and anti coagulate if AF present. Diuretics for pulmonary oedema. Aim to repair or replace valve before severe and irreversible LV dysfunction occurs.
• Tricuspid regurgitation can be caused by right ventricle dilation (due to pulmonary hypertension), rheumatic fever, infective endocarditis and congenital.
• Patients with tricuspid regurgitation can present with hepatic pain, ascites, oedema and signs of pulmonary hypertension if that is the cause.
• Tricuspid regurgitation causes giant V waves on JVP
• Tricuspid regurgitation causes a high pitched systolic murmur best heard over the lower left sternal border. The murmur intensity increases significantly on inspiration.