Changes in Murmurs

by Carlo Raj, MD

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    00:01 Squatting, we talked about this with overview changes in murmur. With squatting rapid, you are going to increase venous return. Most murmurs will increase, what is the big exception that you are going to predict for me? Hypertrophic obstructive cardiomyopathy, more amount of blood in your heart. Remember. HOCM comes under the division of the category of hypetrophic cardiomyopathy and the most common hypertrophic cardiomyopathy will be the obstructive type with what kind of hypertrophy of the interventricular septum? Asymmetrical. Valsalva, what happens? I have been saying this phase over and over again. You have your closed epiglottis for which you are breathing out or expiring. As you do so you increase your thoracic pressure. You are going to squeeze the pulmonic capillaries and you go into phase II. With phase II, you decrease the amount of blood returning to the left side and so, therefore, the intensity of most of the murmurs is going to decrease or are going to decrease. Something that I wish to bring your attention. Yet once again what Valsalva, tell me about MVP, mitral valve prolapse. Four components, what are they? S1, S2. Two down, two to go. Click and murmur, that is your pathology. When you do valsalva, you have decreased amount of blood to the heart. What happens to that click? That click gets closer to S1. It is a not a delayed click, but a shortened click, isn' it? An early click.

    01:26 What then happens to the murmur? It is now lengthened right. What happens to the intensity of the murmur? It increases at valsalva. When we do exercise or rapid squatting and I showed you pictures before in which you would then have increased amounts of blood. The click within get closer to S2 or it is delayed and the murmur shortened. If you understood or if you missed that concept, go back and review. If you have got it down, let us move on. Let's not waste time. Let us be efficient. The two exceptions are exactly here. Two exceptions are systolic murmur here in which with valsalva, with hypertrophic obstructive, it is going to get worse. Mitral valve prolapse, it is going to become longer. What is the murmur? What about the click? It gets early. Exactly what we just went through. Let us continue.

    02:10 Isometric handgrip, what is happening here? It is the fact that when you do a handgrip, you are increasing your TPR. When you increase your TPR, then now here, who haven't talked about this. Well, it is the first time we are seeing this, talked about handgrip, but not in reference to the following murmurs. So murmurs of mitral regurg. So first and foremost, clenching of fist. You constrict your arterials, increase TPR, increase afterload. There is more blood, where? Left in your left ventricle because of increased afterload, increased resistance.

    02:43 We can all agree upon that. Let's say that you have mitral regurg. You tell me quickly mitral regurg difficulty with? Closing. When do your mitral valve close? During systole. It causes systolic murmur between S1 and S2. What kind of murmur? All systolic. You should be able to go through that that quickly and you will. These are steps that you have to take a medicine.

    03:02 Every single time the more organized your thoughts are, the faster that you can run through them, and, therefore, when an attending or an exam asks you a question, you arrive at the answer in a very efficient and quick manner. I know it is never going to leave you. Never. Ventricular septal defect, aortic regurgitation with all of these with a handgrip, you are going to increase intensity of the murmur because of the backup. You can’t move forward. Increase the afterload, increase resistance. Handgrip versus hypetrophic cardiomyopathy, aortic stenosis. Pay attention. Hypertrophic cardiomyopathy, asymmetrical hypetrophy, outflow tract is very very compromised. Thus by handgrip, you increase afterload, the seperation of the outflow tract becomes increased. Thus, the intensity of the murmur is going to decrease. Tell me about aortic stenosis? Normal gradient is high between left ventricle and the aorta to ensure unidirectional flow, correct? Now you do a handgrip, what happens? Less blood passing across this stenotic aortic valve. What happens to the murmur? Decrease in intensity. Tell me about MVP. You have more blood left in your heart. What happens to that click? It gets closer to S2. It is delayed. What happens to murmur? Decreased intensity. There you have it. That mind right there for handgrip probably one of the most important one for manuvers because students tend to get that wrong over, over and over. You understand the pathophys. There is no way that they are going to shake you. You are invincible, my friend. Increased afterload delays left ventricular emptying in HCM. In aortic stenosis, turbulent flow reduced as well due to reduced pressure gradient.

    About the Lecture

    The lecture Changes in Murmurs by Carlo Raj, MD is from the course Valvular Heart Disease.

    Included Quiz Questions

    1. Systolic ejection-type crescendo-decrescendo murmur
    2. Diastolic decrescendo murmur
    3. Opening snap followed by a diastolic low-pitched decrescendo murmur
    4. Blowing holosystolic murmur
    5. Continuous machine-like murmur
    1. Amyl nitrate increases afterload
    2. Isometric hand grip increases afterload
    3. Valsalva phase II decreases preload
    4. Rapid squatting increases preload
    5. Exercise increases preload and decreases afterload
    1. Aortic stenosis
    2. Ventricular Septal Defect
    3. Aortic regurgitation
    4. Mitral regurgitation
    5. Patent ductus arteriosus

    Author of lecture Changes in Murmurs

     Carlo Raj, MD

    Carlo Raj, MD

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