Murmurs - Systolic

Murmurs - Systolic: Excerpt from In a Page: Signs and Symptoms

Systolic heart murmurs, in contrast to diastolic murmurs, may be normal or abnormal, although when coupled with a heave they are always abnormal. The part of the cardiac cycle that the murmur falls into (e.g., early, middle, or late) will help determine the etiology, as will the characteristics of the heart sounds and whether or not a click is present or absent.

Differential Diagnosis

• Innocent systolic murmur
  –Heard at left sternal border
  –Increased when supine
  –May be caused by increased flow states (e.g., anemia, hypovolemia, fever)
• Still's murmur
• Mitral valve prolapse
  –Midsystolic click with late systolic murmur that shifts with maneuvers
• Aortic stenosis
  –Right side at second intercostal space
  –Radiates to carotid arteries
• Aortic sclerosis
  –Right side at second intercostal space
  –Midsystole
• Hyperthyroidism
• Cervical venous hum
  –Disappears with jugular vein pressure
• Hepatic venous hum
  –Disappears with epigastric pressure
• Mammary souffle
  –Occurs in pregnancy
  –Disappears upon compression of breast
• Bicuspid aortic valve
  –Right side at second intercostal space
  –Little radiation
  –Possible early diastolic aortic murmur
  –Opening sound of aortic valve heard in early systole (systolic ejection click)
• Mitral insufficiency
  –Holosystolic murmur heard best in the left lateral decubitus position
  –S₁ is usually diminished in intensity
• Tricuspid insufficiency
  –Holosystolic murmur at second/third intercostal spaces
• Endocarditis
  –Abrupt onset of new murmur
• Peripheral pulmonary artery stenosis
• Atrial or ventricular septal defect
• Ventricular septal defect
• Patent ductus arteriosus (continuous machinery sound, second left intercostal space)
• Coarctation of the aorta
• Left ventricular outflow tract obstruction
• Pulmonary artery stenosis
• Prosthetic valve noises
• Pericardial friction rubs
• Papillary muscle dysfunction
• Pulmonic outflow obstruction
• Coronary/pulmonary arteriovenous fistula

Workup and Diagnosis

• History and physical examination
  –Family history of sudden cardiac death
  –Past medical history of heart disease, murmurs, or rheumatic fever
  –Evaluation for jugular venous distention, carotid upstroke, and/or bruits
  –Heart, lung, and abdominal examinations
  –Peripheral pulses and evaluation for peripheral edema
• ECG
• Chest X-ray
• Echocardiogram
• Laboratory studies may include CBC, electrolytes, BUN/creatinine, glucose, and TSH
• Consider cardiac enzymes
• Consider blood cultures
• Consider cardiology referral

Treatment

• Attention to hemodynamic status
• Treat the underlying cause (e.g., anemia, infection, hyperthyroidism, MI)
• Serial examinations to track progression of underlying cause
• Valve repair/replacement may be indicated for severe valvular disease

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

More About Mitral-valve prolapse

• Back to disease: Mitral-valve prolapse: Introduction
• Next Book Extract About Mitral-valve prolapse: MURMURS (Differential Diagnosis in Primary Care)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

 » Next page: MURMURS (Differential Diagnosis in Primary Care)

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