Differential diagnosis of cardiac murmur. Systolic murmur? Diastolic murmur?

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1 Differential diagnosis of cardiac murmur Systolic murmur? Diastolic murmur?

2 Diastolic murmurs Systole

3 Diastolic murmurs Diastole

4 Diastolic Murmurs Rapid ventricular filling (physiological) Presystolic Aortic insufficiency Pulmonary insufficiency

5 Rapid ventricular filling Physiological Protodiastolic (between S2 and S3), short Grade I to III/VI, localized PMI over the mitral or tricuspid area Wheezing to musical, high-pitched, decrescendo with exercise whoop or 2 years squeak

6 Rapid ventricular filling

7 Differential diagnosis of most common diastolic murmurs Rapid ventricular filling Presystolic Timing Grade PMI Irradiati on Proto I-III Mitr or Tr Character Localised Wheezing to musical, highpitched, Decrescendo with exercise whoop or 2 years squeak Aortic insufficiency Pulmonary insufficiency

8 Diastolic Murmurs Rapid ventricular filling (physiological) Presystolic

9 Presystolic Physiological Telediastolic (between S4 and S1) Grade I to III/VI, localized PMI over the mitral or tricuspid area Roaring, low-pitched Difficult to differentiate from S4

10 Presystolic

11 Differential diagnosis of most common diastolic murmurs Rapid ventricular filling Timing Grade PMI Irradiati on Proto I-III Mitr or Tr Presystolic Tele I-III Mitr or Tr Aortic insufficiency Pulmonary insufficiency Character Localised Wheezing to musical, highpitched, Decrescendo with exercise whoop or 2 years squeak Localised Roaring, lowpitched

12 Diastolic Murmurs Rapid ventricular filling (physiological) Presystolic Aortic insufficiency

13 Epidemiology: - Valvular insufficiency the most υ in older horses - Mainly > 10 years old Murmur: Aortic insufficiency - Characteristic - Holo to pandiastolic - Decrescendo - PMI over aortic area, irradiating towards the l apex - Grade υ high: III to VI/VI - Roaring to musical

14 Aortic insufficiency

15 Aortic insufficiency Clinical signs: - Rarely with clinical signs; asymptomatic for a long duration - υ with non significant arrhythmias (AV block or PVC) - Pulse amplitude= the best clinical indicator of evolution into CHF - If CHF => Cfr clinical signs of mitral insufficiency

16 Aortic insufficiency Signs of favourable prognosis - Clinical signs: Normal resting HR No sign of CHF, EI or significant arrhythmias Normal arterial pulse amplitude - Echo Doppler: AoV: no nodular lesion, prolapsus No diastolic vibration of valves/septum Reflux limited in surface; P 1/2 prolonged No signs of LV volume overload No mitral insufficiency No worsening on CTR echo

17 Aortic insufficiency Signs of un favourable prognosis - Clinical signs: Resting HR > 45/min Signs of CHF, EI or significant arrhythmias Bounding arterial pulse - Echo Doppler: AoV: nodular lesion, valve thickening Severe reflux (surface); P 1/2 short Signs of LV volume overload Mitral insufficiency Dilation Ao/Pu Rapid worsening on CTR echo

18 Differential diagnosis of most common diastolic murmurs Timing Grade PMI Irradiati on Character Rapid ventricular filling Proto I-III Mitr or Tr Presystolic Tele I-III Mitr or Tr Localised Wheezing to musical, highpitched, Decrescendo with exercise whoop or 2 years squeak Localised Roaring, lowpitched Aortic insufficiency Pulmonary insufficiency Holo to pan I-VI Ao Ventrally Roaring to musical Decrescendo

19 Diastolic Murmurs Rapid ventricular filling (physiological) Presystolic Aortic insufficiency Pulmonary insufficiency

20 Differential diagnosis of most common diastolic murmurs Timing Grade PMI Irradiati on Character Rapid ventricular filling Proto I-III Mitr or Tr Presystolic Tele I-III Mitr or Tr Localised Wheezing to musical, highpitched, Decrescendo with exercise whoop or 2 years squeak Localised Roaring, lowpitched Aortic insufficiency Holo to pan I-VI Ao Ventrally Roaring to musical Decrescendo Pulmonary insufficiency Holo to pan Pu Difficult to hear

21 Conclusions Clinical signs: Differential diagnosis - physiological - pathological Doppler Echocardiography: Confirmation of the diagnosis Prognosis

22 Epidemiology: - Rarely isolated: Murmur: Pulmonary insufficiency Most υ repercussion of a left heart disease - Difficult to detect

23 Murmurs: Conclusions Clinical signs: Differential diagnosis - physiologic - pathologic Dopppler echocardiography: To confirm the diagnosis To give a more accurate pronosis

24 Murmurs in horse Clinical examination Differential diagnosis Clinical cases