EpistemisPalpable cardiovascular thrill (Thrill)
Specialty: Cardiovascular.
Why it occurs
- Severe aortic stenosis (systolic thrill in the second right intercostal space)
- Large ventricular septal defect (systolic thrill at the lower left sternal border)
- Severe mitral stenosis (palpable diastolic thrill at the apex)
- Severe pulmonary stenosis (systolic thrill in the second left intercostal space)
- Massive mitral regurgitation or papillary muscle rupture (apical systolic thrill)
Initial workup
Two-dimensional transthoracic echocardiogram and emergency continuous/pulsed Doppler to immediately confirm the nature of the murmur (septal defect, rupture of the valve apparatus or severe valve stenosis) and quantify the Qp/Qs shunt or the transvalvular gradient; Chest x-ray to evaluate acute pulmonary congestion or extreme cardiomegaly; 12-lead electrocardiogram; Cardiac catheterization if hemodynamic confirmation is required.
red flags
Detection of a fine tactile vibration, comparable to the purring of a cat, palpable in the anterior chest wall or suprasternal hollow, of sudden onset after an acute myocardial infarction (suggesting rupture of the interventricular septum or rupture of chordae tendineae of the mitral valve), or that is associated with severe dyspnea at rest, profound arterial hypotension, cold sweating, altered state of consciousness or signs of shock cardiogenic. Indicates a high intensity murmur (grade IV/VI or higher) caused by highly turbulent flow through a defect or severely damaged valve; requires urgent cardiothoracic evaluation.
Standard management
- Nitroglycerin — intravenous vasodilator indicated if the thrill is due to acute mitral insufficiency to reduce left ventricular afterload and facilitate antegrade flow, closely monitoring blood pressure; infusion 5 to 50 mcg/min
- Sodium nitroprusside — ultra-fast acting arterial vasodilator, useful in acute mitral insufficiency or interventricular septal rupture to reduce afterload and shunt; infusion of 0.3 to 3 mcg/kg/min under invasive monitoring
- Furosemide — loop diuretic to control pulmonary congestion resulting from acute valve failure; 40 to 80 mg intravenous bolus
- Norepinephrine (vasopressor indicated if there is associated severe hypotension, with the objective of maintaining basic tissue perfusion pressure; dose-response infusion).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Cardiovascular
- Listed causes
- 5
- Treatment options
- 4