Hear Murmurs, Dan Boboia

1) Different types of murmurs?

Still's murmur - located at inferior aspect of lower left sternal border(LLSB), there is a systolic ejection sound, vibratory/musical quality; can be caused by subaortic stenosis, small VSD

- Pulmonary ejection - located at superior aspect of LLSB, ejection sound can be caused by atrial septal defect or pulmonary stenosis

- Venous hum- infraclavicular throughout the cardiac cycle (right side > left side), diminishes with jugular vein palpation or neck turning, common cause is PDA

- Supraclavicular arterial bruit; located above clavicles can be caused by aortic stenosis, bicuspid aortic valve

- Peripheral pulmonary stenosis; low-pitch with radiation to back and armpit can be cause by PDA, pulmonary stenosis
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Murmurs can be classified by seven different characteristics: timing, shape, location, radiation, intensity, pitch and quality.
· Timing refers to whether the murmur is a systolic or diastolic murmur.
· Shape refers to the intensity over time; murmurs can be crescendo, decrescendo or crescendo-decrescendo.
· Location refers to where the heart murmur is auscultated best. There are 6 places on the anterior chest to listen for heart murmurs; the first five out of six are adjacent to the sternum. Each of these locations roughly correspond to a specific part of the heart. The locations are: 2nd right intercostal space, 2nd - 5th left intercostal spaces, and 5th mid-clavicular intercostal space.
· Radiation refers to where the sound of the murmur radiates. The general rule of thumb is that the sound radiates in the direction of the blood flow.
· Intensity refers to the loudness of the murmur, and is graded on a scale from 0-6/6.

Grading of Murmurs Grade Description
· Grade 1 Very faint
· Grade 2 Soft
· Grade 3 Heard all over the precordium
· Grade 4 Loud, with palpable thrill (ie, a tremor or vibration felt on palpation)
· Grade 5 Very loud, with thrill. May be heard when stethoscope is partly off the chest.
· Grade 6 Very loud, with thrill. May be heard with stethoscope entirely off the chest.

· The pitch of a murmur is low, medium or high and is determined by whether it can be auscultated best with the bell or diaphragm of a stethoscope.
· Some examples of the quality of a murmur are: blowing, harsh, rumbling and musical.
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2) Which murmurs require prophylaxis.

All murmurs associated with the conditions on Table 2 (Infective Endocarditis: Dental Implications and New Guidelines for Antibiotic Prophylaxis)

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3) Acyanotic vs. Cyanotic Heart Defects

Acyanotic Types

· Left to Right Shunt Lesions – causing volume overload distal to the shunt with secondary congestive heart failure; symptoms: dyspnea, poor feeding, recurrent pneumonia, pulmonary congestion
· Obstructive Lesions – pulmonary stenosis, aortic stenosis, peripheral pulmonary stenosis, coarctation of the aorta; symptoms: limitation of exercise tolerance, chest pain or syncope, congestive heart failure and death if left untreated.
· Primary Pump Failure – dialated cardiomyopathy, myocarditis, anomalous origin of a coronary artery from the pulmonary artery

Cyanotic Congenital Heart Disease

1) Abnormal communication Proximal to Right-Sided Obstruction – right to left shunt when the right- and left sided pressures in the proximal chambers equalize (Tetrology of Fallot).
2) Abnormalities of Alignment Between Various Segments – D-transposition of the great arteries
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4) Best way to communicate with a physician

Through a phone consult and ultimately a form of documentation that will end up in the patient's dental chart. If a pathological condition exists a cardiologist is often involved (usually a better resource then a primary care physician; more appropriate to obtain a consult from especially in cases of significant cardiac abnormality).