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Welcome to episode 91 of the Audio PANCE and PANRE Physician Assistant/Associate Board Review Podcast.

Today is part one of an extraordinary five-part series with Joe Gilboy PA-C, all about cardiac murmurs.

It’s time to throw away everything you have ever learned that made you hate cardiac murmurs (you know those crazy line diagrams) and let Joe hard-wire your brain for success.

I promise you that by the end of this podcast, you will no longer be afraid of murmurs, but you will welcome them into your brain with a whole heart, open arms, and the need to share this podcast with all your classmates.

Below is a transcription of this podcast episode slightly edited for clarity.

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Welcome, everybody. This is Joe Gilboy PA-C, and today is part one of a five-part series on the two most dreaded words that every pa student and recert PA hates. Are you ready for the two words?

Heart murmurs!

Today we’re going to start talking about heart murmurs, and we are going to break this down into a five-part series:

1. The first part is going to be on the aortic valve (today’s episode)
2. The second part will cover the mitral valve
3. The third will be all about the pulmonic valve
4. The fourth part will be about the tricuspid valve
5. And then, in the fifth part of this series, we’re going to wrap this all together

We’re going to cover each valve one at a time. We will look at it and try to really make sense of it all.

Because I know what you did in PA school, you had that little diagram that you made, you know, systolic or diastolic murmurs. You’ve memorized certain things. And then you get to that test question, and you’re completely clueless on it, you’re like, “I have no idea what they just said, Joe, I have no idea.”

And then you’re back to scrambling, looking for some word that’s going to trigger you. And that’s the key point- all the trigger words, all those high-value trigger words, they’re gone. That’s what the creators of the PANCE did about two to three years ago. They took all the trigger words out.

Key point:

• Don’t rely on keywords (trigger words) for your PANCE because they’re gone!

So now, let’s look at this differently. You did it your way. How did it work out? Probably not so well. So, guess what, we’re going to do it my way. And that’s what I want to do here.

Let’s start with the aortic valve.

So, think about it for a second. I want you to picture the aortic valve.

Opening during systole, closing during diastole. That’s really what it’s supposed to do.

Go ahead and picture that in your head. And for those who are in a safe place, close your eyes because it makes more sense.

The valve is going to be open during systole and is going to be closed during diastole.

Now, who gets fed right after the aortic valve? Well, that’d be the coronary arteries.

If I’m lacking blood flow to my coronary arteries, how’s that feel? I’ve got chest pain.

What’s the second thing that gets fed after the aortic valve? Well, that’d be my internal and external carotid arteries.

If I lack blood flow to my internal or external carotids, how will I feel? Lightheaded with syncope and dizziness.

Where does blood flow third? That would be my left subclavian artery, and if I lack blood flow, then I get left arm pain. And then, of course, everything down south after that.

Aortic Stenosis

Okay, so let’s start with the first one—aortic stenosis.

So, think about this for a second. Stop memorizing. Start thinking. I have this stenotic aortic valve, and it can’t open up. So that’s my question to you. When are you going to have problems with this valve? During systole or diastole?

It is supposed to open during systole. And it won’t. It’s too stenotic.

The aortic valve is supposed to be closed during diastole, and it will close. Oh, then I see your point, then that is a systolic murmur. Right? Aortic stenosis is a systolic murmur!

Where’s the aortic valve located? The right second intercostal space. And where does it radiate to? The neck.

I want you to understand something. Who’s got to work harder to push against this stenotic aortic valve. Who’s got to work harder to open the door? It’s the left ventricle.

Okay, you’re the body. Are you going to take this, or are you going to fight back? I’m going to fight back a little bit, Joe.

So, what’s going to happen to the left ventricle? The left ventricle is going to hypertrophy.

And then go and stretch and stretch and stretch and stretch and stretch and stretch and stretch that left ventricle and you’re going to rupture the wires in there. And you’re going to get left bundle branch block.

And for those of you thinking, ahead of the game, will right ventricular hypertrophy, unopposed cause right bundle branch block? The answer is yes.

Back to aortic stenosis – I see the left ventricular hypertrophy because it’s backing up. I can even see the left bundle branch block. That makes sense.

So, aortic stenosis is a systolic ejection murmur. Oh, I see it because it’s supposed to be open during systole. But it’s a tight valve, and it won’t open up. I get it!

Let’s go one step further. It’s the most commonly acquired valvular stenosis, and usually, it’s congenital or from a bicuspid valve. But that’s not what they’re going to ask. That’s too easy. So, how would aortic stenosis present? That’s the right question.

Let’s say you have a stenotic aortic valve; it’s not opening during systole. “Hi, I have aortic stenosis, and I’m walking through Costco.”

So, you are walking through Costco, looking at the Christmas decorations or whatever they have. And how is your valve? Is it opening up? Yes, or no? No, it’s not Joe. And are you demanding more of it? You’re walking through Costco. How’s the blood flow to your coronary arteries? Oh, it’s diminished. Exactly.

Then I get chest pain with exertion – exactly. I could be walking up steps – and that’s the test question you see rear its ugly head – it’s going about the person with chest pain who’s walking up steps or exerting himself.

And then how’s your blood flow to your head? I get lightheaded and dizzy because of a lack of blood flow there. Get it? Do you see this picture?

I have this murmur in the right second intercostal space. It’s going to be systolic. The person is going to complain of chest pain