1. Where is the aortic systolic murmur of valvular AS heard loudest?
ANS: Anywhere in a straight line from the second right interspace to the apex. (If the patient is obese or has emphysema, the murmur may be loudest above or on the clavicle.)
2. Where is the classic "aortic area?" What is wrong with this term?
ANS: This area is in the second right interspace. However, aortic valvular events can be best heard anywhere in a "sash" or "shoulder harness" area from the second right interspace to the apex.
Since aortic ejection murmurs and clicks are often best heard at the apex area, and aortic regurgitation murmurs are usually best heard along the left lower sternal border or midsternum, it should no longer be taught that the "aortic area" is the second right interspace.
3. What term should we use instead of aortic area?
ANS: The second right interspace. It is confusing to a student to be told that aortic murmurs and ejection sounds are often best heard at the left sternal border or apex and then to hear the second right interspace called the aortic area.
4. What is characteristic of the upward radiation of an aortic murmur?
ANS: a. It tends to radiate into the neck bilaterally but often radiates well along the innominate vein, making the murmur slightly louder on the left.
b. It not only radiates well to the right clavicle but is usually amplified there. Any murmur louder over the carotid than on the clavicle should be considered a local arterial murmur .
Note: Innocent aortic ejection murmurs are characteristically maximal along the left sternal border near the anatomical aortic valve area. With significant aortic valvular obstruction, however, the maximum turbulence occurs further downstream from the orifice and tends to be loudest at the second right interspace.
5. What is the significance of a soft A2 in a patient with a loud ejection murmur?
ANS: It almost always indicates severe AS because the soft A2 implies heavy calcification of the valve.
6. How soft can the murmur of a severe AS become if heart failure develops with a resultant reduced stroke volume?
ANS: It may almost disappear.
7. Why may the murmur of severe AS be soft in the elderly in the absence of heart failure?
ANS: a. There is commonly an increased anteroposterior chest diameter in the elderly, especially at the base of the heart. b. The stiff cusp bases and lack of commissural fusion may cause some of the blood to be ejected between the cusps in the form of a "spray" rather than a jet. This may make the murmur not only more musical but also less loud and harsh.
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Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...