cardiac clinical examination

7/25/2019 Cardiac Clinical Examination

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Cardiac Physical Diagnosis:

A Proctor Harvey Approach

By

Keith A. McLean, M.D.


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Cardiac Physical Diagnosis

The great maority o! diagnosis o!

cardiovasc"lar disease can #e made at

the o!!ice or the #edside.

$s"ally yo" do not need sophisticated,

elegant la#oratory e%"ipment.


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The complete cardiovasc"lar e&aminationconsists o! the ' !inger method:

history

physical e&am

(C)

chest &*ray

simple la#oratory tests. History is generally the most important.


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P"ls"s alternans: A p"lse that alternates

amplit"de +ith each #eat. i.e. -T/0),

+ea1, -T/0), +ea12

3o" may miss it i! yo" palpate +ith very

!irm press"re4 "se light press"re li1e a

#lo+ o! #reath on o"r !ingers.


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The Harvey method is:

5. 6nspection, ta1e time to loo1 closely

7. -tart at the le!t lo+er sternal #order !oran overvie+. Listen to the !irst so"nd,

then the second so"nd, then so"nds in

systole, m"rm"rs in systole, and so"nds in

diastole and m"rm"rs in diastole.


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-8 gallop is heard #etter and lo"der +iththe patient:

in the le!t lateral dec"#it"s position

a!ter palpating the PM6, 1eeping yo"r!inger on the location o! the PM6 andplacing the #ell o! the stethoscope over

the PM6 The gallop may alternate in intensity +ith

every other #eat and press"re on thescope can eliminate the gallop.


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P(AL: -8 or -9 may #e missed in an

emphysemato"s chest +ith an increase in

AP diameter secondary to C/PD, i! yo"

listen at the "s"al space, LL-B or ape&.

6! yo" listen over the &yphoid or epigastric

area, it may easily detected.


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)allops are diastolic !illing so"nds -8 and-9.

The #est position to hear gallops, as they

may only #e heard in the le!t lateraldec"#it"s position, over the PM6 +ith the#ell #arely ma1ing a seal +ith the chest

+all. irm press"re diminishes or eliminates -8

or -9.


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Ho+ to di!!erentiate #et+een an -9, a split -5,

and an eection so"nd:

-9 is eliminated +ith press"re on the

stethoscope Press"re does 0/T eliminate eection so"nds or

a split -5

-9 is "s"ally 0/T heard over the aortic area Aortic eection so"nd 6- heard over the aortic

area


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A -9 is !re%"ently !o"nd in patients +ith

coronary artery disease.

Harvey says: ;6! an -9 isn


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-9 is a common !inding in patients +ith

HT0.

Harvey personal approach4 ;6! the -9 is

present and the #lood press"re is 59>?@>

or greater, medication is indicated !or

HT0, #eca"se the presence o! the -9

already means that the heart has #eena!!ected.=


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S3 Gallop

-8 is not a lo"d so"nd. Most o! them are

!aint.

Most -8


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S3 Gallop

-ome instr"ctors have "sed the +ords

;Tennessee= and ;Kent"c1y=.

Ten*nes*see -9. Ken*t"c1*y -8.

These are o!ten con!"sing and are

disco"raged.


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Congestive Heart Failure

The earliest, most s"#tle signs and

!indings o! cardiac decompensation are:

P"ls"s alternans

-8


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Hydrothorax

6t accompanies CH and may #e #ilateral. More

commonly presents in the right thora&. hy

)ravity

Patients are more li1ely to sleep on their rightside. Patients +ith large hearts and arrhythmias

s"ch as a !i# are conscio"s o! the heart action

+hile lying on the le!t, there!ore they pre!er to

sleep on their right side.


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Hydrothorax

P(AL: hen a le!t hydrothora& is

present in a patient +ith heart disease,

r"le o"t the possi#ility o! an etiology otherthan heart !ail"re.


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Cheyne*-to1es respirations, +hich "s"ally

indicates very advanced heart !ail"re. 6t

can also indicate cere#rovasc"lar disease

or dr"g e!!ects, s"ch as narcotics.


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hen it is not possi#le to control atrial!i#rillation a!ter trying severalantiarrhythmic dr"gs, it may #e #est !or

#oth physician and patient to accept andlive +ith a chronic atrial !i#rillation +ith aventric"lar rate in the >


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The Inching Technique

The inching techni%"e is the most

acc"rate and most practical +ay o! timing

e&tra heart so"nds and m"rm"rs.

The stethoscope is moved or ;inched=

do+n over the precordi"m !rom the aortic

area to the ape&.


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The Inching Technique

3o" can also start at the ape& and LL-B

and inch "p+ard to+ards the #ase o! the

heart.

irst, start over the aortic area,

remem#ering that the second heart so"nd

over the aortic area is almost al+ays

lo"der than the !irst.


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Aortic egurgitation

Positions and techni%"es !or a"sc"ltation:

The m"rm"rs o! aortic reg"rgitation are

generally heard +hen the patient is sitting

"pright, leaning !or+ard, #reath held in

deep e&piration.


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Aortic egurgitation

$sing !irm press"re o! the !lat diaphragm

o! the stethoscope and listening along the

8rd le!t sternal #order.

There sho"ld #e !irm press"re on the

stethoscope, eno"gh to leave an imprint o!

the diaphragm chest piece on the chest

+all, +hich may #e necessary to #ring o"ta !aint m"rm"r, grade 6 or 66.


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Aortic egurgitation

A !aint aortic diastolic m"rm"r may #e

overloo1ed i! only the #ell o! the

stethoscope is "sed.


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Aortic egurgitation

/ther positions !or a"sc"ltation o! the diastolicm"rm"r o! aortic reg"rg:

5. hen the patient lying on his or her stomach,and propped "p on the el#o+s. Also this position

is "se!"l to detect a pericardial !riction r"#. 7. The patient standing, leaning !or+ard +ith

his?her hands on the +all. The great maority o! m"rm"rs o! aortic

reg"rgitation are heard lo"der at the le!t sternal#order compared +ith the co"nterpart on theright.


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Aortic egurgitation

Ho+ever, some diastolic m"rm"rs are #est

heard along the right sternal #order rather

than the le!t.

The right*sided aortic diastolic m"rm"r is

"s"ally associated +ith dilatation and

right+ard displacement o! the aortic root.


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Aortic egurgitation

This has #een associated +ith: *aortic ane"rysm *aortic dissection

*HT0 *arteriosclerosis *rhe"matoid spondylitis *Mar!an


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Aortic egurgitation

The 1ey interspaces are the 8rd and 9thright, as compared +ith their co"nterparts,the 8rd and 9th le!t interspaces.

The 8rd interspaces are more li1ely tosho+ the de!initive di!!erence.

An aortic diastolic m"rm"r lo"der at the

right sternal #order than the le!timmediately s"ggests the diagnosis "stdescri#ed.


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Aortic egurgitation

Another cardiac P(AL concerning right*

sided aortic diastolic m"rm"rs is +hat +e

term a !orm"la.

Diastolic G aortic diastolic G right*sided

HT0 m"m"r aortic diastolic

m"rm"r


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Aortic egurgitation

Ane"rysm and or dissection o! the !irstportion o! the ascending aorta.

-evere pain in the "pper #ac1 #et+een

the sho"lder #lades is a cl"e to an aorticdissection.

6! the chest &*ray sho+s right+ard

displacement o! the aortic root and am"rm"r o! aortic reg"rgitation is present, itis most li1ely to #e the right*sided type.


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Aortic egurgitation

6! atrial !i#rillation is present, s"spect the

possi#ility o! concomitant mitral valve

lesions.


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Aortic egurgitation

/ther !indings o! severe aorticreg"rgitation incl"de:

typical "p and do+n #o##ing o! the head,

dem"sset


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Aortic egurgitation

Proctor Harvey says yo" sho"ld palpate

sim"ltaneo"sly the radial, #rachial or

carotid p"lse +ith the !emoral p"lse. 6! the

carotid, #rachial or radial p"lsations are#etter !elt than the !emoral, diagnose

coarctation o! the aorta in addition to

severe aortic reg"rgitation.


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Aortic egurgitation

The nec1 pain !rom aortic reg"rgitation

can #e a transient tenderness and pain

over the carotid arteries, may #e

characteried #y e&acer#ations andremissions that are "na!!ected #y aortic

valve s"rgery, the etiology o! +hich is

"ncertain, pro#a#ly prod"ced in the +all o!the carotid artery*co"ld #e !rom carotid

p"lsations against tender lymph nodes.


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Aortic egurgitation

The patient +ith aortic reg"rgitation has a lo"d

aortic systolic m"rm"r, even +ith a palpa#le

systolic thrill.

ith aortic reg"rgitation, at the ape& generally alocalied spot over the le!t ventricle is #est heard

+ith the patient in the le!t lateral dec"#it"s

position. Listen +ith the #ell o! the stethoscope

over the PM6. A diastolic r"m#le may #epresent. This is the A"stin*lint r"m#le.


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Aortic egurgitation

6n Proctor Harvey


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Aortic egurgitation

The %"ic1 rise, or !lip, o! the radial p"lsemay #e even #etter detected #y havingthe patient raise his arms over his head.

This simple mane"ver may ma1e this typeo! p"lse more evident.

The prompt recognition o! ac"te severeaortic reg"rgitation as can occ"r !romin!ective endocarditis a!!ecting the aorticvalve may #e li!e*saving.


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Aortic egurgitation

The !ail"re to do so is "nderstanda#le

#eca"se the diastolic #lood press"re may

#e lo+*normal or #e slightly or moderately

red"ced compared +ith the very lo+diastolic #lood press"re present +ith

severe chronic ac"te reg"rgitation.


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Aortic egurgitation

Also, +ith the ac"te type, the to and !rosystolic and diastolic m"rm"rs heard #estalong the le!t sternal #order may #e

shorter in d"ration and !ainter. Also, the!irst heart so"nd is li1ely to #e !aint.

(arly clos"re o! the mitral valve is d"e to agreat lea1 o! the aortic valve into the le!tventricle, there#y closing the mitral valvepremat"rely.


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Aortic Stenosis

The typical m"rm"r o! aortic stenosis is

harsh, similar to the so"nd o! clearing

one


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Aortic Stenosis

Aortic stenosis m"rm"r is heard e%"ally

lo"d on #oth sides o! the carotid arteries.

Palpation can #e o! great aid in the clinical

diagnosis o! aortic stenosis "sing #othhands4 the right hand is placed over the

ape& o! the le!t ventricle and le!t hand over

the aortic area.


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Aortic Stenosis

Le!t ventric"lar imp"lse indicating hypertrophy o!

the le!t ventricle can #e !elt, and a palpa#le

systolic thrill may #e detected over the aortic

area, the direction o! +hich is to+ards the rightnec1 and sho"lder.

The direction o! the thrill +ith aortic stenosis is

to+ards the right nec1 or clavicle.

The direction o! the thrill o! p"lmonic stenosis isto+ards the le!t nec1 or clavicle.

Di!! ti ti "it l


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Di!!erentiating "itral

egurgitation !ro# Aortic

Stenosis a!ter a Pause

The systolic m"rm"r o! mitral reg"rgitation

remains "nchanged a!ter a pa"se. 6n contrast the systolic m"rm"r o! aortic

stenosis is lo"der a!ter a pa"se !ollo+ing a

premat"re #eat.


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There may #e +ide transmission o! aortic

systolic m"rm"r over the entire precordi"m, may

#e heard over the aortic area, the p"lmonic

area, the 8rd le!t sternal #order, the le!t lo+ersternal #order, and the ape&.

Aortic events are o!ten clearly heard at the ape&.

Aortic stenosis m"rm"rs are "s"ally +idelytransmitted thro"gho"t the nec1 as +ell.


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The systolic m"rm"r is o!ten lo"der overthe clavicles, ill"strating the importance o!transmission #y #one.

The radial p"lse, #rachial and carotid maysho+ a slo+ rise +ith a slo+ descent,+hich is consistent +ith aortic stenosis.

Proctor Harvey s"ggests that thediagnosis o! aortic stenosis may #e made!rom palpation alone.


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Aortic Stenosis

Concentrate on the m"rm"r a!ter a pa"se

+ith atrial !i#rillation or +ith a pa"se a!ter a

premat"re #eat.

ith aortic stenosis, the m"rm"rincreases in intensity a!ter a pa"se.


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Aortic Stenosis

ith mitral reg"rgitation, the m"rm"r

remains essentially "nchanged.

P(AL: The M"sical M"rm"r

6! one hears a high*!re%"ency, m"sical,

diamond*shaped systolic m"rm"r heard

only at the ape&, immediately thin1 o! and

r"le o"t aortic stenosis.


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Aortic Stenosis

6t is clinically apparent that the typical

harsh, lo+ !re%"ency m"rm"r o! aortic

stenosis can #e !iltered or altered #y

emphysemato"s changes and an increasein diameter to res"lt in this m"sical

m"rm"r.


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"itral egurgitation

Ho+ever, i! one thin1s that there is only

single aortic lesion, s"ch as aortic

stenosis, +hen atrial !i#rillation is present,

al+ays loo1 care!"lly !or concomitantmitral valve involvement.


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"itral egurgitation

Care!"l search may then detect, !or

e&ample, an "ns"spected mitral stenosis,

a r"m#le o! +hich may only #e detected

+hen the patient is t"rned onto the le!tlateral position and the physician listens

over the PM6 +ith the #ell o! the

stethoscope held lightly and #arelyto"ching the s1in o! the chest +all.


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The heu#atic Heart

Another cardiac P(AL is the rhe"maticheart.

6! only the aortic valve is diseased, it is

most li1ely 0/T o! rhe"matic etiology. he"matic heart generally has 7 valves

involved, the aortic and the mitral.

Cardiac P(AL: 6n men, the aortic valveis most li1ely to #e diseased. 6n +omen,it


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Syncope in Aortic Stenosis

The patient having symptoms o! syncope,

near syncope, or diiness related to

severe, advanced aortic stenosis sho"ld

#e promptly re!erred !or s"rgical valvereplacement.

Their ne&t episode o! syncope co"ld #e

their last.


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Systolic "ur#urs o! the $lderly

As people live longer, they o!ten developan aortic systolic m"rm"r that mayprogressively increase in intensity,

prod"ce symptoms o! !atig"e, dyspnea,near syncope or syncope.

This is "s"ally ca"sed #y a tric"spid aorticvalve.

This is the most common ca"se o! valvestenosis in patients age >*@> yrs old.

The Innocent Systolic "ur#ur in


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the $lderly

*can happen in elderly patients +ith

systolic m"rm"rs over the aortic area as

+ell as the p"lmonic area.

(lderly people ages >*@> develop anaortic systolic m"rm"r d"e to a mild to

moderate degree o! sclerosis or stenosis.



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the $lderly

Calci"m deposits o! varying degree occ"r

on the valve, #"t may not a!!ect its

!"nction and the patient may have no

symptoms. This m"rm"r is termed ;innocent systolic

aortic m"rm"r o! the elderly=.

$s"ally no treatment is re%"ired, nor isheart catheteriation necessary.



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the $lderly

The pathology o! valve sho+s dense

sclerotic changes +ith calci!ication o!

portions o! the three lea!let aortic valve.

The commiss"res are not !"sed at their"nction +ith the aortic ring.



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the $lderly

Altho"gh a m"rm"r o! grade 8 or less may

have #een heard in a patient +ith s"ch a

valve, no symptoms may #e present.

They may have a !aint 5 or 7 aorticdiastolic m"rm"r.



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the $lderly

An innocent m"rm"r o! the elderly more

li1ely in males2 may contin"e a #enign

co"rse !or years4 on the other hand,

progression can grad"ally occ"r andca"se symptoms.


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Cardiac P$A%

-ometimes, "ne&plained )6 #leeding

occ"rs in patients +ith aortic stenosis.

ollo+ing an operation !or aortic stenosis,

the #leeding +as alleviated. /!ten noe&planation +as !o"nd.


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&icuspid Aortic 'alve

rom ages to appro&imately >, #ic"spid

aortic valve is the most li1ely ca"se o!

aortic stenosis, and ran1s second only to

mitral valve prolapse as the most commonvalv"lar lesion.



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or e&ample, i! aortic stenosis is

diagnosed in a man aged '' and it is a

single valv"lar lesion, the diagnosis in the

great maority o! patients +ill #e congenital#ic"spid aortic valve.

Calci!ication o! the valve +ill #e present in

virt"ally 5>>I o! these patients.



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A!ter the age o! >, the most commonca"se o! aortic stenosis is not congenitalin origin, #"t rather a three lea!let

tric"spid2 aortic valve. Cardiac P(AL: 6! the aortic valve is

involved as a single lesion, the heartrhythm is reg"lar. 6! atrial !i#rillation is

present, al+ays s"spect and r"le o"tconcomitant mitral valve pathology.


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6t is o! great importance to di!!erentiate the

m"rm"r o! congenital aortic stenosis !rom

an innocent systolic m"rm"r.

(arly diagnosis can #e readilyaccomplished in the physician


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re%"ently, it has a harsh %"ality similar to

the so"nd o! clearing one


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irm press"re on the stethoscope


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-ince aortic events are "s"ally +ell heard at theape&, the systolic m"rm"r o! aortic stenosis may

#e detected !rom the aortic area to the ape&.

This is also tr"e o! the aortic eection so"nd thatis another 1ey to this condition.

Congenital #ic"spid aortic valve eection so"nd

is "nchanged #y respiration and is the same

over the p"lmonic area, the 8rd L-B, and at theLL-B.


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The eection so"nd is not eliminated +ith

!irm press"re o! the stethoscope, as

sho"ld #e the case +ith an atrial gallop.

Cardiac P(AL: The eection so"nd is ahallmar1 o! a congenital #ic"spid aortic

valve and occ"rs +ith ;doming= o! the

valve in early systole.

&i id A i ' l


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6t is o! interest that, as part o! the

spectr"m o! !indings in congenital #ic"spid

aortic valve, aortic reg"rgitation rather

than stenosis may #e the dominant lesionand in perhaps 'I o! cases it may #e o!

an advanced, severe degree.

Ho( to Di!!erentiate Congenital &icuspid Aortic

St i ! I t "


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Stenosis !ro# an Innocent "ur#ur

An innocent m"rm"r +ill have no eection so"nd,and +o"ld #e associated +ith a normal (K) and

chest &*ray.

(K) may sho+ a#normalities s"ch as le!t a&isdeviation and some increase in voltage over the

le!t ventricle, consistent +ith LFH.

The chest &*ray may sho+ some post*stenotic

dilatation o! the ascending aorta or other variant!rom normal.

Ch t P i


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Chest Pain

Cardiac P(AL: 6! possi#le, try to o#tainan (K) +hile the patient still has the

chest pain.

6t is also help!"l to have the patient havean (K) d"ring any arrhythmia or

palpitation or other symptom o! +hich he

complains.

! !


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Pain o! "yocardial In!arction

*severe precordial s"#sternal discom!ortthat radiates "p to the le!t sho"lder and

then do+n the le!t arm and along the

inside o! the arm rather than the o"tside. At times, #oth the right and le!t arms are

involved +ith the radiation o! the pain, and

in rare patients the pain is more noticea#lein the right arm than the le!t.

P i ! " di l I ! ti


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The pain may also radiate "p into the nec1,more li1ely the le!t, #"t sometimes the right or

#oth sides o! the nec1.

/ccasionally, the pain seems to #e localied inthe a+, ma1ing the patient thin1 that this is a

pain in a tooth.

Descriptions o! the classic chest pain may !eel

;li1e an elephant stepping on my chest= or alasso aro"nd the chest p"lling tighter and tighter.

P i ! " di l I ! ti


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-+eating !re%"ently accompanies themore severe pain o! an ac"te myocardial

in!arction.

0a"sea and vomiting may also #epresent.

The patient cannot seem to !ind a position

+here there is relie! !rom the pain.

P i ! " di l I ! ti


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To elicit a description o! the typical painca"sed #y myocardial ischemia, as1 the

%"estion, ;hat happens i! yo" +al1

#ris1ly "p a hill, against the +ind, in cold+eather=

P i ! " di l I ! ti


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Levine


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As a variant o! this sign, the patient maypress over this area +ith the e&tended

!ingers o! #oth hands4 less commonly, the

patient points and presses +ith one !inger"s"ally the inde& !inger2 over the

s"#sternal area in descri#ing the

discom!ort.

P i & t th Sh ld


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Pain &et(een the Shoulders

Chest pain more localied in the sho"lders or#et+een the sho"lder #lades in the #ac1 sho"ldalert one to the possi#ility o! aortic dissection.

Altho"gh, the pain o! ac"te myocardial in!arction

can indeed radiate to this area in the #ac1, thelocaliation o! the pain in the sho"lder regionand the #ac1 also is very consistent +ith thepain ca"sed #y r"pt"re o! the aorta.

Be especially s"spicio"s i! the (K) does notindicate myocardial in!arction.

P i & t th Sh ld


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Pain &et(een the Shoulders

/ccasionally, a patient +ill descri#e theradiation o! the ischemic pain !rom

coronary artery disease as #eing ;li1e an

advancing tidal +ave=, !rom the s"#sternalarea to the le!t sho"lder and then do+n

the le!t arm to the !ingertips. hen the

pain #egins to s"#side, the ;tidal +ave=reverses direction #ac1 to the heart.

) C Ch t P i


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)on*Coronary Chest Pain

6t is +orth+hile to e&plain to patients thetype o! chest pain that generally is 0/T

related to heart disease:

*A constant ;aching= pain that might #e inthe s"#sternal area and lasts all day is

"s"ally not ca"sed #y heart disease.

0or is pain that is present only in oneposition and not in others.

)on Coronar Chest Pain


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)on*Coronary Chest Pain

*Coronary pain is not accent"ated #ye&ternal press"re over the precordi"m.

*Pain over the apical region o! the heart or

over the right anterior chest region is nottypical o! coronary artery pain.

*The !leeting, momentary pain in the chest

descri#ed as a needle a# or stic1, lastingonly a second or t+o, is not heart pain.

$ar %o+es


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$ar %o+es

At times yo" may see movement o! the patient


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Carcinoid Tu#or


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Carcinoid Tu#or

hen !l"shing occ"rs or the patient haspersistent violaceo"s or erythemato"s

!acial !l"shing, then the carcinoid t"mor o!

the intestine has metastasied to the liver. The serotonin in the #loodstream o!

patients +ith the carcinoid syndrome can

ca"se scarring o! the p"lmonic valve,prod"cing the p"lmonic systolic m"rm"r.

In!ective $ndocarditis


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In!ective $ndocarditis

Anti#iotic prophyla&is as o"tlined #y the AHA isindicated not only !or e&tractions o! teeth #"talso !or the simple proced"res o! cleaningand?or !illing.

6n!ective endocarditis has #een de!initelydoc"mented to occ"r +ith these simplerproced"res.

Anti#iotic prophyla&is sho"ld also #e given to

patients +ith valv"lar heart disease. 6n!ectiveendocarditis can also a!!ect valves replaced ats"rgery.

"itral 'alve Prolapse


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6t sho"ld #e policy to give anti#ioticprophyla&is to ALL patients +ith mitral

valve prolapse*those having a clic1 or

clic1s, as +ell as those patients +ith asystolic m"rm"r.

-ome a"thorities recommend prophyla&is

only !or patients +ith mitral valve prolapse+ho have a systolic m"rm"r.



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Harvey disagrees +ith this, as he can citemany patients +ith MFP +ho have

transient m"rm"rs as +ell as clic1s.

He has personally o#served patients +ithproven in!ective endocarditis +ho had only

a single clic1 or clic1s and never had a

systolic m"rm"r detected on care!"la"sc"ltation.


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At times, proper and e!!icient a"sc"ltation overthe chest and nec1 is accomplished #y having

the patient stop #reathing.

6n this +ay #reath so"nds are not inter!ering. hen +e as1 the patient to do so, +e too,

sho"ld also stop #reathing. This reminds "s

+hen to tell the patient to res"me #reathing4 i!

+e don


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-ometimes a partic"larly garr"lo"s patientcontin"es to tal1 +hile +e try to listen4

several things are help!"l:

politely as1 to please stop tal1ing say ;let me see yo"r tong"e=

say ;hold yo"r #reath

The Five ,ear ule


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The Five ,ear ule

A ne+ dr"g, proced"re, techni%"e or pieceo! e%"ipment sho"ld ideally stand the test

o! time J a#o"t !ive years J #e!ore it is

!"lly "tilied. 6! at the end o! this ;+atching= period

nothing negative has evolved, then it may

#e "tilied as indicated.

Innocent Systolic "ur#urs


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The innocent systolic m"rm"r is short,occ"rring in early to mid systole. 6t is not

holosystolic. 0ormal splitting o! the

second heart so"nd is present also. The innocent systolic m"rm"r is very

common. 6t is a !re%"ent !inding in

children and teenagers, and less li1ely inad"lts.



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/"t o! 5>> school children aged 55 or 57,Harvey !o"nd appro&imately >I +ho had an

innocent systolic m"rm"r.

6t is also o! interest that in this partic"lar gro"p,he !o"nd 5>>I had a normal physiologic third

heart so"nd4 5>>I had a normal physiologic

veno"s h"m that +as detected listening over the

right s"praclavic"lar !ossa, +ith the head t"rned;on a stretch= to the opposite direction.


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"ur#urs o! pathologic conditions can +e

si#ilar to innocent #ur#urs +ut they have


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si#ilar to innocent #ur#urs- +ut they have

other associated !indings.

or e&ample, atrial septal de!ect has a+ide, so*called ;!i&ed= splitting o! the

second heart so"nd.

The (K) has changes, partic"larly in leadF5: right ventric"lar cond"ction delay

-52, BBB or FH.

"ur#urs o! pathologic conditions can +e

si#ilar to innocent #ur#urs +ut they have


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si#ilar to innocent #ur#urs- +ut they have

other associated !indings.

The &*ray sho+s increased #lood !lo+ inthe l"ngs and enlarged p"lmonaryarteries.

The m"rm"r o! a congenital #ic"spidaortic valve can in itsel! #e similar to theinnocent m"rm"r, #"t an eection so"nd ispresent +ith the aortic stenosis +hich is

+ell heard over the precordi"m !rom theaortic area to the ape&.

%ocation


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%ocation

A common misconception is that aninnocent m"rm"r is localied over one

area, s"ch as the p"lmonic area, third le!t

sternal #order, or aortic area. 6nstead, innocent m"rm"rs are !re%"ently

heard in other areas o! the precordi"m,

altho"gh they may #e lo"dest over onepartic"lar area.

Innocent systolic #ur#urs


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are commonly !o"nd in children and in theearly teen years. They are less common

in ad"lts.

An interesting e&ception is the !act thatinnocent systolic m"rm"rs +ere !o"nd in

more than @>I o! @> 0L players

personally e&amined.



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6nnocent systolic m"rm"rs occ"r in earlyto mid*systole.

They are generally )rade 5*8 in intensity

and in the great maority are readilydiagnosed in the o!!ice or at the #edside.

The second heart so"nd is o! normalintensity, normally split and the degree o!

splitting increases in normal !ashion +ithinspiration.



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More sophisticated la#oratory st"diess"ch as echocardiography and cardiac

catheteriation are "s"ally not necessary

!or diagnosis and only add to the e&penseinc"rred #y the patient or !amily.

Di!!erentiation !ro# other


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conditions

6nnocent systolic m"rm"rs are o!tensimilar to m"rm"rs ca"sed #y a #ic"spid

aortic valve, mild p"lmonic stenosis, or

atrial septal de!ect. Ho+ to tell thedi!!erence

Consider the concomitant !indings.

Di!!erentiation !ro# other conditions


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A m"rm"r d"e to a #ic"spid aortic valve has an

aortic eection so"nd that is "na!!ected #yrespiration.

A m"rm"r d"e to congenital valv"lar p"lmonic

stenosis also has an eection so"nd #"t it +ill

vary, #ecoming !ainter or even disappearing on

inspiration, altho"gh heard lo"der on e&piration.

The m"rm"r o! p"lmonic stenosis also is more

li1ely to have a +ider split o! the second heartso"nd that does not #ecome single on

e&piration.

FH may #e noted on the (K).



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ith a m"rm"r d"e to A-D, there is +ide;!i&ed= splitting o! the second heart

so"nd.

This !inding, together +ith the (K) and&*ray changes o! A-D, can %"ic1ly ma1e

the distinction #et+een this serio"s

m"rm"r and an innocent m"rm"r.



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6nnocent m"rm"rs are #etter heard in yo"ngpeople +ho have thin chests than in those +ho

are o#ese or m"sc"lar.

/nce the diagnosis o! innocent m"rm"r is

esta#lished, it is not +ise or necessary to have

the patient ret"rn at intervals o! several months

or a year to 1eep chec1 on this m"rm"r.

/ther+ise, it can #e logically interpreted: ;Thedoctor is not s"re4 i! not, +hy do 6 have to

ret"rn=

6nnocent M"rm"rs


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9 s -o!t

-hort

-ystolic

-plit normal split s72

Systolic "ur#ur in the $lderly


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-ystolic m"rm"rs in the elderly pop"lation arean e&pected and "s"ally innocent !inding.

They are "s"ally grade 5 to 8 in intensity and

#est heard over the aortic area or le!t sternal

#order4 it may also #e heard over the clavicles

#one transmission24 in the s"prasternal notch,

s"praclavic"lar areas o! the nec1, incl"ding over

the carotid arteries.



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The m"rm"r !re%"ently has a some+hatm"sical %"ality and can #e transmitted

do+n to the ape&. -ometimes it can even

#e #etter heard at the ape&. /ccasionally a !aint aortic diastolic

m"rm"r grade 5 or 72 is heard in addition

to the systolic m"rm"r.

Cardiac Pearl


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Cardiac Pearl

The person +ho care!"lly s1etches +hat isheard on a"sc"ltation #ecomes

progressively more e&pert in the art o!

a"sc"ltation. 0ever has an e&ception #een seen.

Grading Systolic "ur#urs


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)rading o! systolic m"rm"rs is importantand very help!"l. They are graded !rom 5

to #ased on a system introd"ced #y the

late -am"el A. Levine:



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)rade 5: the !aintest m"rm"r that onehears +ith the stethoscope, #"t o!ten is

not detected immediately.

)rade 7: is also a !aint m"rm"r, #"t one+ill hear it immediately on placing the

stethoscope over the chest.

)rade 8: is still on the !aint side, #"t islo"der than the )rade 7 m"rm"r.



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/n the opposite end o! the grading scale,)rade is the lo"dest m"rm"r and can

even #e heard +itho"t the stethoscope

act"ally to"ching the chest +all. Ho+ever, as long as one can see daylight

#et+een the stethoscope and the chest

+all and still hear a m"rm"r, it is a )rade m"rm"r.



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)rade ' is also a lo"d m"rm"r, #"t it is notheard "nless the stethoscope is act"ally

to"ching the chest +all.

)rade 9 is a lo"d m"rm"r and is asigni!icant "mp in intensity !rom )rade 8.

)rade 9 m"rm"rs and a#ove can #e

accompanied #y a palpa#le systolic thrill

Intensity o! "ur#ur


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Intensity o! "ur#ur

6! a palpa#le systolic thrill is !elt, them"rm"r is at least a )rade 9 intensity.

Cardiac Pearl


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Cardiac Pearl

Al+ays r"le o"t aortic stenosis in a patient+ith the !ollo+ing !indings:

A very high pitched m"sical systolic

m"rm"r that pea1s in mid*systole and can#e heard over the precordi"m altho"gh it

may #e detected only at the ape&2

heart so"nds that may #e distant ora#sent.


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Cardiac Pearl


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Ca d ac ea

There!ore, in M and F-D, there is earlieremptying o! the #lood !rom the le!t

ventricle +ith systole, res"lting in earlier

clos"re o! the aortic component o! thesecond so"nd, there#y prod"cing a +ider

split.

Cardiac Pearl


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An early to mid*systolic m"rm"r, +ithnormal splitting o! the second heart so"nd,

pl"s an intermittent third heart so"nd is a

per!ectly normal !inding i! there are nosymptoms or signs o! heart disease.

Diastolic "ur#urs


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Aortic diastolic m"rm"rs can #e lo"d andcan #e ca"sed #y varying etiologies.

They can #e associated +ith a palpa#le

thrill along the third le!t sternal #order.-ometimes the m"rm"r has a ;to and !ro=%"ality, lo"d +ith a very lo+, some+hatm"sical %"ality.

-ometimes the diastolic m"rm"rresem#les sa+ing +ood, +ith the lo"dcomponent #eing in diastole.

Pregnancy


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A !aint grade 5 or 7 early, #lo+ing diastolic

m"rm"r o! aortic reg"rgitation might not #edetected in a pregnant +oman, partic"larly in

her last trimester.

emem#er, also, that almost all pregnant+omen have an innocent grade 7 or 8 early to

mid systolic m"rm"r, +hich may not #e heard

#e!ore or a!ter her pregnancy.

Most pregnant +omen have innocent veno"sh"ms in the nec1 and innocent systolic

m"rm"rs.



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p

Mitral valve prolapse is synonymo"s +ithother terms s"ch as: -ystolic clic1*m"rm"r syndrome

Billo+ing mitral valve lea!let syndrome loppy valve syndrome

Barlo+


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p

The mitral valve is made "p o! t+o #asiccomponents: a !i#rosa element and aspongiosa element.

6n this condition, the spongiosa elementproli!erates. (&cessive lea!let tiss"e canca"se a scalloping or hooding e!!ect o! thevalve.

There may #e thinning and elongation o!the chordae tendinae.

Detecting "itral 'alve Prolapse


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g p

Mitral valve prolapse o!ten is !irstdiagnosed #y echocardiogram.

3o"r stethoscope, ho+ever, is still the #est

instr"ment to detect and diagnoseprolapse o! the mitral valve.



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g p

Both the echocardiogram and angiogramcan !ail to doc"ment prolapse.

6t also can #e missed #y the stethoscope4

ho+ever, generally that is #eca"se thephysician is not ;mentally set= to listenspeci!ically !or the typical a"sc"ltatory!indings, or has not listen care!"lly in a

%"iet room +ith the patient in the !ollo+ingpositions:



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g p

-"pine T"rned to the le!t lateral position

-itting

-tanding -%"atting

Falsalva Mane"ver

As a r"le, !indings o! mitral valve prolapse on

a"sc"ltation are #est detected "sing the !lat

diaphragm chest piece o! the stethoscope.



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g p

The !indings may #e transient, intermittent,varying at times, +ith some heart#eatshaving:

0o clic1 or m"rm"r /nly a clic1 or clic1s

/nly a m"rm"r

Com#inations o! clic1 and m"rm"r A m"sical m"rm"r termed ;+hoop= or

;hon1=



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The great maority o! patients +ith mitralvalve prolapse are completely

asymptomatic and need no treatment.

-ome patients have palpitations and adegree o! chest discom!ort.



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/ccasionally sedatives, #eta*#loc1ers andantiarrhythmics are needed and may #e

e!!ective in treatment, altho"gh some

patients hare not helped #y these dr"gs. The most serio"s complication is r"pt"re

o! a chorda tendinea, +hich may occ"r

spontaneo"sly or as a res"lt o! in!ectiveendocarditis on the valve.

Co#plications and Associated

Findings o! "itral 'alve Prolapse


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Progressive, increasingly severe M "pt"red chordae tendinae

"pt"re o! valve lea!let

Calci!ication o! mitral ann"l"s

Transient ischemic attac1s

Co#plications and Associated



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Arrhythmias Chest pain

6n some patients, symptoms compati#le

+ith ne"rocirc"latory astheniaDaCosta


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-ystolic clic1s generally occ"r in mid tolate systole. Ho+ever, a seldom

recognied variant o! mitral valve prolapse

is that they can occ"r in early to midsystole.

They can #e m"ltiple and rapid and can

sim"late the !lipping o! a dec1 o! cards orthe crea1ing o! ne+ leather.

Seldo# ecogni/ed 'ariant o!



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6t can sim"late and #e misdiagnosed as apericardial !riction r"# #eca"se o! thesem"ltiple rapid so"nds in systole.

A pericardial !riction r"# has 7 or 8components rather than only one insystole:

the atrial systolic

the ventric"lar systolic the ventric"lar diastolic

Di!!erentiating "itral 'alve Prolapse

!ro# Innocent Systolic "ur#ur


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This di!!erentiation generally is not di!!ic"lt. The typical m"rm"r o! mitral valve

prolapse is in mid to late systole, +hereas

the innocent m"rm"r is in the early to midportions o! systole. A clic1 or clic1s2

!re%"ently accompanies the m"rm"r o!

mitral valve prolapse #"t is a#sent +ith aninnocent m"rm"r.




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A mane"ver that increases vol"me to thele!t side o! the heart, s"ch as s%"atting,

may delay these a"sc"ltatory !indings,

and there!ore the clic1 or m"rm"r maymove closer to the second heart so"nd.




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/n prompt standing and +ith a decrease invol"me they may move in the opposite direction

in systolecloser to the !irst heart so"nd.

Also contri#"ting is the #ending o! the 1nees and

hips, +hich can increase peripheral arterial

systolic press"re, and ca"se movement closer

to the second so"nd, and closer to the !irst

so"nd on standing.


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$0ection Sound Ter#inology


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6t is s"ggested that the term ;systolic clic1=#e reserved !or and identi!ied +ith mitral

valve prolapse.

"itral 'alve Prolapse*Chest

A+nor#alities


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A+nor#alities

hen +e !ind on e&amination o! o"rpatients that there is a chest anomaly

s"ch as straight #ac1, pect"s e&cavat"m,

pect"s coronat"m, or chest asymmetry,+e have a cl"e that mitral valve prolapse

might #e present.

Perhaps '>I o! patients +ith s"chanomalies may have mitral valve

prolapse.

Hypertrophic Cardio#yopathy


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0o+ let


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e e&pect to hear the early #lo+ingdiastolic m"rm"r o! aortic reg"rgitation4

ho+ever, +e don


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The ne&t step is to "se the s%"attingmane"ver.

/n s%"atting, the m"rm"r decreases in

intensity on rare occasions it may evendisappear2.

The m"rm"r #ecomes lo"der again on

standing, and the diagnosis o!hypertrophic cardiomyopathy is made.



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e term this the ;one, t+o, three, !o"r diagnosis=o! hypertrophic cardiomyopathy.

0"m#er one: +e !ind the %"ic1 rise p"lse

0"m#er t+o: +e loo1 !or aortic reg"rgitation

0"m#er three: +e don


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-imple and more e!!ective +ay:

The patient stands !acing the physician,steadying himsel! or hersel! +ith the le!t hand onthe e&amining ta#le.

The physician listens +ith the stethoscope overthe patient


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The Falsalva mane"ver, too, can #ehelp!"l in diagnosing hypertrophiccardiomyopathy.

hile listening along the le!t sternal #orderor ape&, have the patient ta1e a deep#reath, #lo+ the #reath o"t and then strainas i! having a #o+el movement.

The m"rm"r may increase in intensity,indicating a positive response.



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Ho+ever, some patients, s"ch as theelderly, may have di!!ic"lty in per!orming

this mane"ver.

A simple and e!!icient +ay is to have thepatient place his inde& !inger in his mo"th,

seal it +ith his lips, e&hale and at the point

o! deep e&piration, ;#lo+ hard= on the!inger.


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Precordial 6mp"lse: ith the patientt"rned to the le!t lateral position and

palpating over the point o! ma&im"m

imp"lse o! the le!t ventricle, three imp"lsesmay #e !elt: The presystolic movement and a do"#le

systolic imp"lse. This is called the ;triple

ripple= imp"lse associated +ith hypertrophiccardiomyopathy.

Aortic Stenosis v1s Hypertrophic

Cardio#yopathy


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Cardio#yopathy

Altho"gh #oth valv"lar aortic stenosis andhypertrophic cardiomyopathy can, +ith more

severe degrees o! o#str"ction, prod"ce

parado&ical splitting o! the second heart so"nd,

it is m"ch more common in patients +ithhypertrophic cardiomyopathy.

At times, di!!erentiating the systolic m"rm"r o!

hypertrophic cardiomyopathy !rom that d"e tor"pt"re o! chordae tendinae can #e %"ite di!!ic"lt

indeed.

Cardiac Pearl


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The di!!erentiation o! these t+o similarm"rm"rs: 6! parado&ical splitting o! the second heart

so"nd in present in the a#sence o! le!t#"ndle #ranch #loc1 on the (K)2 the

diagnosis sho"ld immediately #e made o!

hypertrophic cardiomyopathy.

$2G Signs o! Hypertrophic

Cardio#yopathy


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y p y

6n the a#sence o! any history, symptoms, orsigns o! coronary artery disease, the presence

o! signi!icant *+aves and -T and T +ave

changes sho"ld alert one to the possi#ility o!

hypertrophic cardiomyopathy*partic"larly in a

teenager or yo"ng ad"lt.

A normal (K) practically r"les o"t the diagnosis

o! hypertrophic cardiomyopathy. Dilatedcardiomyopathy, too, o!ten has some

a#normality o! the (K).

"itral egurgitation


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Holosystolic: A holosystolic pansystolic2m"rm"r s"ggests three conditions: mitral

reg"rgitation, tric"spid reg"rgitation, and

ventric"lar septal de!ect. 6! a m"rm"r is holosystolic, this !inding

alone immediately ta1es it o"t o! the

#allpar1 o! innocent m"rm"rs, +hich areearly to mid*systolic.

"itral egurgitation


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6! the holosystolic m"rm"r radiates #and*li1e li1e a #elt2 !rom the LL-B to the ape&,

anterior mid and posterior a&illary lines

and even to the posterior l"ng #ase, this isdiagnostic o! mitral reg"rgitation.

adiation o! the Systolic "ur#ur

o! "itral egurgitation


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g g

ith signi!icant posterior lea!let damage,the radiation is anterior, "p+ard over the

precordi"m to the #ase4

6! anterior lea!let damage predominates,then the radiation is apt to #e posterior,

!rom the ape& to the a&illary lines and

posterior l"ng #ase.

"itral egurgitation as a Single

'alvular %esion


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6! a patient has mitral reg"rgitation alone,and no other signi!icant !indings, yo" can

#e almost certain it is noto! rhe"matic

etiology as !ormerly tho"ght, #"t related toa complication o! mitral valve prolapse,

s"ch as !loppy valve or r"pt"re o! a chorda

tendinea.

Acute "itral egurgitation


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The m"rm"r o! severe ac"te mitralreg"rgitation is lo"d grade 9 or a#ove2,occ"pies all o! systole, pea1s in mid*systole and decreases in the letter part o!systole.

Altho"gh +omen have a higher incidenceo! mitral valve prolapse, men are more

li1ely to have r"pt"re o! chordaetendineae, prod"cing mitral reg"rgitation.

"itral egurgitation


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Mitral reg"rgitation is also a ca"se o! +idesplitting o! the second so"nd.

ith systole, #lood is eected thro"gh the "s"al

aortic o"t!lo+ trac1 and sim"ltaneo"sly thro"gh

the incompetent mitral valve into the le!t atri"m.

The le!t ventric"lar contents there#y empty

earlier than "s"al, and the aortic valve clos"re

A72 is earlier, +hich res"lts in a +ider split in#oth e&piration and inspiration.

"itral egurgitation


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All valv"lar lesions can, at times, #e;silent= +ith no m"rm"r.

The most common silent lesion is mitralstenosis#"t the maority o! these, !ail"reto detect a m"rm"r is #eca"se the #ell o!the stethoscope is not over the PM6, alocalied spot +hich may #e the sie o! a

%"arter2 +here the diagnostic r"m#le isheard.

"itral egurgitation


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A third heart so"nd -82 is an e&pected !inding inthe more advanced, more severe lea1s o! themitral valve.

A short diastolic r"m#le may also #e heard in

s"ch patients. These a"sc"ltatory !indings are ca"sed #y the

large vol"me o! #lood in the enlarged le!t atri"m!iling the ventricle and prod"cing, in the rapid

!illing phase, the third so"nd pl"s lo+*!re%"encyvi#rations. This r"m#le is "s"ally not the res"lto! stenosis o! the mitral valve.

"itral Stenosis


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6! a diastolic r"m#le o! mitral stenosis ispresent it is almost al+ays heard over thePM6 o! the LF +ith the patient t"rned to thele!t lateral position.

-ometimes one has di!!ic"lty in palpatingthis imp"lse.

Almost al+ays, an opening snap o! mitral

stenosis is heard, even +ith the moste&tensive degree o! stenosis.

%oud First Heart Sound


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6! a patient +ho has a normal heart rate has alo"d !irst so"nd, al+ays thin1 o! t+o conditions:

mitral stenosis and a short P* interval on the

(K).

The length o! a P* interval can a!!ect the !irstheart so"nd. The increase in intensity o! the

so"nd is most li1ely d"e to the position o! the A*

F valves at the time systole occ"rs.

6! the valves are deeper in the ventricles and

systole occ"rs promptly a!ter the atrial systole,

the valves close, ma1ing a lo"der so"nd.

%oud First Heart Sound


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6! the P* interval is prolonged and the A*F valves have had time to move "p+ard inthe ventricles, systolic contractionprod"ces a !aint !irst so"nd.

A lo"d !irst heart so"nd d"e to a short P*interval can sim"late the so"nd o! mitralstenosis.

The presence o! a normal physiologic thirdheart so"nd can #e misinterpreted as anopening snap.


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Graha# Steell "ur#ur


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6t has #een said that one cannot tell thedi!!erence #et+een the diastolic m"rm"r o!p"lmonary reg"rgitation )raham -teell2associated +ith mitral stenosis and that o!

aortic reg"rgitation associated +ith mitralstenosis.

The m"rm"r o! aortic reg"rgitation may #e

heard over the aortic area and transmittedalong the LL-B to the ape&.

Graha# Steell "ur#ur


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The )raham -teell m"rm"r is not heardover the aortic area and o!ten is localied

to the LL-B and generally not heard at the

ape&. The peripheral p"lse has a %"ic1 rise ;!lip=

+ith aortic reg"rgitation and not +ith the

)raham -teell m"rm"r.


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He#optysis


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Hemoptysis can occ"r in the patienthaving advanced tight mitral stenosis.

ort"nately, the #leeding, +hich is d"e to

a r"pt"re o! a #ronchial vein, is generallysel! limited and does not represent an

emergency sit"ation.

He#optysis


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Ho+ever, there have #een isolated casereports +here the #leeding did notspontaneo"sly s"#side and s"rgery +asnecessary to control it.

P"lmonary em#oli can also ca"sehemoptysis +ith mitral stenosis as +ell as+ith other conditions. This can represent

a serio"s complication re%"iring promptrecognition and treatment.

Di!!erential Diagnosis o! the openingsnap o! #itral stenosis and 3rdheart

sounds


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(&ert press"re on the stethoscope,+hich sho"ld eliminate the normal thirdheart so"nd or the -8 ventric"lar2diastolic gallop4 press"re on the

stethoscope is not li1ely to eliminate theopening snap.

The opening snap is heard over the

p"lmonic area sometimes aortic area2#"t not the third so"nd.

Di!!erential Diagnosis o! the openingsnap o! #itral stenosis and 3rdheart

sounds


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The opening snap o! a ;tight mitralstenosis= is closer to the second so"nd

than the third so"nd.

The opening snap serves as a cl"e tolisten over the PM6 o! the LF !or the ;tell

tale= diastolic r"m#le*not so +ith the third

so"nd, +hich does not initiate the

diastolic r"m#le.

CADIAC P$A%


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: 6n a +oman o! appro&imately 8> years o!age, +ho never had any previo"s heart

pro#lem and then had a s"dden onset o!

an arrhythmia, the diagnosis that sho"ldhead the di!!erential is mitral valve

prolapse.


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Atrial Flutter


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hen the P +ave is !arther !rom the +ave, the !irst heart so"nd is !aint.

This is +hat ca"ses the changes in

intensity o! the !irst heart so"nd incomplete heart #loc1.

Atrial Fi+rillation


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The "ne&plained onset o! atrial !i#rillationin a patient +ho is '> years or older may

#e a cl"e to the presence o! "nderlying

coronary artery disease. Ho+ever, this is not necessarily tr"e, since

other conditions can ca"se this.

Heart &loc


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hen the P* interval on the (K) isshort, the !irst heart so"nd may #e lo"d.

/n the other hand, in the same patient,

+hen the P* interval is prolonged s"chas in !irst*degree heart #loc12 the !irst

heart so"nd may #e !aint.

The intensity o! the !irst heart so"nd +illrelate to the length o! the P* interval.


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Heart &loc


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This res"lts in a changing intensity o! the!irst heart so"nd4 at intervals, +hen the P*

interval is short, an a#r"pt lo"d !irst

so"nd the ;#r"it de canon= or ;cannonshot=2 occ"rs +hich is an a"sc"ltatory

!inding diagnostic o! complete heart #loc1.

Heart &loc


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Cannon 4ave o! the 5ugular 'enous Pulse The diagnosis o! complete heart #loc1 can #e

s"spected #y paying attention to the "g"lar

veno"s p"lsations in the nec1 and #y o#serving

a slo+ reg"lar heart rate appro&imately 9> #pm2.

6! a s"dden ;cannon +ave= occ"rs, it indicates

that atrial contraction is occ"rring sim"ltaneo"sly+ith ventric"lar contraction.

This is common +ith complete heart #loc1.


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I#pulses o! Hypertrophy


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6n s"ch circ"mstances, the (K) maysho+ another diagnostic cl"e: Persistent elevation o! the -*T segments in

the le!t precordial leads.

The com#ination o! this imp"lse pl"s thepersistent electrocardiographic !indings inthe a#sence o! ac"te in!arction +here the

same !indings may #e present2 indicatesle!t ventric"lar ane"rysm, most li1ely d"eto an old myocardial in!arction.

Palpation


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6t is important to palpate over the #ase o!the heart.

A palpating hand can !eel:

A lo"d p"lmonic valve clos"re o! P7A systolic eection so"nd

A systolic thrill o! p"lmonic valve stenosis

A right ventric"lar li!t +ith the #ottom heel2 o!

the palm

Palpation


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A palpating hand can !eel:A lo"d aortic valve clos"re o! A7

An aortic systolic eection so"nd

A systolic thrill o! aortic stenosisA diastolic thrill o! aortic reg"rgitation

The Signi!icance o! a

Paradoxical Pulse


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The term ;parado&ical p"lse= is really amisnomer #eca"se +hen it is clinically

apparent, it is really only an e&aggeration

o! the normal p"lse. The decrease in amplit"de o! the p"lse

coincident +ith inspiration may #e o! help

in diagnosing constrictive pericarditis.

The Signi!icance o! aParadoxical Pulse


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Parado&ical p"lse also is an importantsign o! pericardial tamponade, and may

#e a sign o! restrictive cardiomyopathy, or

chronic p"lmonary disease s"ch asemphysema or asthma.

Signi!icance o! a +is!eriens pulse


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The do"#le systolic imp"lse in the radial,#rachial, carotid or !emoral arterial p"lse is

called a #is!eriens p"lse.

hen this is present, thin1 o! threepossi#ilities:A com#ination o! aortic stenosis pl"s aortic

reg"rgitation

more severe aortic reg"rgitation

hypertrophic cardiomyopathy.

5ugular 'enous Pulse


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The #est +ay to detect the speci!ic +aveso! the "g"lar veno"s p"lse in the nec1 is

to #e a#le to -(( #oth the veno"s

p"lsation and the carotid arterial p"lsation

in the same localied area.

6! +e detect a p"lsation o! the "g"lar vein

"st #e!ore that o! the carotid artery, then

this has to #e an A*+ave.


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5ugular 'enous Pulse


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There are only a !e+ conditions thatca"se a ;giant= A*+ave in the "g"lar

veno"s p"lse:

P"lmonary hypertension ;(isenmengersyndrome=2* p"lmonary hypertension, +ith

atrial de!ect, ventric"lar de!ect, and patent

d"ct"s arterios"s2 can ca"se press"re to #e

re!lected #ac1 to the right ventricle, +hichprod"ces an A*+ave +ith atrial systole.


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The First Heart Sound


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-plitting o! the !irst so"nd is d"e to clos"re o! themitral valve !ollo+ed #y tric"spid valve clos"re.

The second so"nd split is d"e to aortic valve

clos"re !ollo+ed #y tric"spid valve clos"re.

0ormally, le!t sided events o! the heart occ"r#e!ore the right4 there!ore the mitral valve

clos"re component occ"rs #e!ore the tric"spid

valve clos"re component o! the !irst heart so"nd

and the aortic valve clos"re #e!ore the p"lmonic

valve clos"re o! the second heart so"nd.


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The First Heart Sound


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ide -plitting: ide splitting o! the !irst heart so"nd can

occ"r +ith complete le!t #"ndle #ranch #loc1,complete right #"ndle #ranch #loc1, (#stein


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Atrial Septal De!ect


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6t is rare that a grade 7 or grade 8 systolicm"rm"r is not heard in early or midportions o! systole in patients +ith atrialseptal de!ect.

6n addition, +ith complete right #"ndle#ranch #loc1, the second heart so"ndgenerally has more movement that the so*

called ;!i&ed= splitting o! atrial septalde!ect.


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/!ten the only cl"e to an osti"m prim"mde!ect is le!t a&is deviation on the (K).

Also, +ith the larger sh"nts at the atriallevel, a ;!lo+= r"m#ling m"rm"r may #eheard along the lo+er le!t sternal #order4this is the res"lt o! the increased !lo+ o!#lood sh"nted !rom the le!t atri"m to the

right side o! the heart, prod"cing a moret"r#"lent !lo+ across the tric"spid valve.



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/! co"rse, occasionally an innocent p"lmonicsystolic m"rm"r can #e present in a patient

having right #"ndle #ranch #loc1.

Ho+ever, the total cardiovasc"lar eval"ation can

ma1e the correct diagnosis. or instance, the chest &*ray +ill sho+ the atrial

de!ect +ith an enlarged p"lmonary artery

segment, pl"s increased vasc"lar mar1ings.



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A simple mane"ver is to have the patient sit orstand "p4 i! the second so"nd then #ecomessingle, or very closely split on e&piration, this ismost li1ely a normal variant, and not the +idesplitting o! atrial septal de!ect.

Ho+ever, ;never say neverN= /ccasionally, asmall atrial septal de!ect can have a single orclosely split -7 +ith e&piration.

Also, remem#er that the absenceo! a systolic

m"rm"r even !aint2 heard over the p"lmonicarea or le!t sternal #order practically eliminatesthe diagnosis o! atrial septal de!ect.



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A patient +ith atrial septal de!ect +o"ld have+ide, !i&ed splitting o! the second heart so"nd

and a systolic m"rm"r o! grade 7 or 8.

There +o"ld #e (K) changes, partic"larly noted

in F5, s"ch as right ventric"lar cond"ction delay,indicated #y an -5.

/r the patient +o"ld have incomplete right

#"ndle #ranch #loc1, complete right #"ndle

#ranch #loc1, or right ventric"lar hypertrophy.



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The &*ray +o"ld sho+ an enlargedp"lmonary artery segment +ith increased

vasc"lar mar1ings, and the

echocardiogram might sho+ !indings

consistent +ith atrial septal de!ect.

The echocardiogram and cardiac

catheteriation co"ld, o! co"rse, doc"ment

this.



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ide splitting o! the second heart so"nd alsocan #e !o"nd in patients +ith anomalo"s veno"s

ret"rn.

This de!ect is o!ten associated +ith atrial septal

de!ect #"t, "ncommonly, it does occ"r alone4 ins"ch cases the second heart so"nd is more

li1ely to have more movement o! the split +ith

respiration than that o! the typically ;!i&ed

splitting= o! atrial septal de!ect.


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Second Heart Sound


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ider splitting can also occ"r in patients +ithlarge ventric"lar septal de!ects4 the mechanism

is similar to that o! mitral reg"rgitation.

ith parado&ical splitting o! the second heart

so"nd, the reverse o! normal splitting ta1esplace. 6nstead o! the degree o! splitting

increasing +ith inspiration, the splitting is +ider

+ith e&piration and more closely split or single

+ith inspiration.

Second Heart Sound


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Complete le!t #"ndle #ranch #loc1 is associated+ith delayed electrical cond"ction to the le!t sideo! the heart, +hich there#y delays le!t ventric"larcontraction.

hile aortic valve clos"re normally precedesp"lmonic valve clos"re, in patients +ith le!t#"ndle #ranch #loc1 the order may #e reversed.ith e&piration, there!ore, P7 may occ"r #e!ore

A7, +ith inspiration P7 moves to+ard it, res"ltingin close splitting, or a single second so"nd4 +ithe&piration the splitting is +ider again.


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Atrial Septal De!ect v1s Pul#onicStenosis


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/sti"m sec"nd"m septal de!ect and a mildcongenital p"lmonic valve stenosis can have

#oth similar m"rm"r and a +ider split o! the

second so"nd that does not #ecome single on

e&piration. Ho+ to tell the di!!erence Presence o! a p"lmonic systolic eection so"nd

immediately indicates p"lmonic stenosis.

The eection so"nd may decrease in intensity or

disappear on inspiration.



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The presence o! le!t a&is deviation on the (K)sho"ld #e an immediate cl"e to change thediagnosis o! sec"nd"m de!ect to that o! prim"mde!ect.

$nless lead F5 on the (K) sho+s -5, rightventric"lar cond"ction delay, right #"ndle #ranch#loc1, or right ventric"lar hypertrophy, #eca"tio"s in ma1ing the diagnosis o! atrial septalde!ect.

The great maority o! patients +ith atrial septalde!ect +ill have one o! these !indings.



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A#sence o! a -ystolic M"rm"r The a#sence o! a systolic m"rm"r practically

r"les o"t the diagnosis o! "ncomplicated

osti"m sec"nd"m atrial septal de!ect.

The Second Heart Sound6Pul#onary Hypertension


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As a r"le, +ith p"lmonary hypertension o! asigni!icant degree, the p"lmonic component o!

the second so"nd #ecomes greatly accent"ated

and splitting "s"ally #ecomes closer.

P"lmonary hypertension o! this 1ind may occ"r+ith ventric"lar septal de!ect, atrial septal de!ect,

patent d"ct"s arterios"s, primary p"lmonary

hypertension, or rec"rrent p"lmonary em#oli.

The Second Heart Sound6Pul#onary Hypertension


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The second heart so"nd #ecomes %"itelo"d and easily palpa#le.

6! p"lmonary hypertension is associated

+ith an atrial septal de!ect, more distinctsplitting o! the second heart so"nd

generally is heard and is one clinical cl"e

to atrial de!ect.

Friction u+


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A !riction r"# is "s"ally #est heard over thethird or !o"rth le!t sternal #order "sing the

diaphragm chest piece o! the stethoscope

pressed !irmly against the chest +all.

-"spect ac"te pericarditis +hen a patient

says, ;6 have pain in my chest +hen 6 am

lying do+n, #"t 6 can get relie! i! 6 sit "p

and get in a certain position=.


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Pericardial 2noc Sound


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6t may #e misinterpreted as the openingsnap o! mitral stenosis.

Ho+ever, in timing it occ"rs later a!ter the

second so"nd than does the opening snapo! a tight mitral stenosis, #"t earlier than

the normal physiological third heart so"nd

or ventric"lar -82 gallop.


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Ho( to di!!erentiate the opening snap o! #itralstenosis !ro# the pericardial noc sound o!

constrictive pericarditis


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The diastolic m"rm"r o! mitral stenosis is"s"ally heard over the point o! ma&im"mimp"lse o! the le!t ventricle.

A diastolic m"rm"r is hardly ever present

+ith constrictive pericarditis. An e&ception: Fery very rarely,

constriction #et+een the le!t atri"m and

le!t ventricle has occ"rred, res"lting in adiastolic m"rm"r.

Ho( to di!!erentiate the opening snap o! #itralstenosis !ro# the pericardial noc sound o!

constrictive pericarditis


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0ec1 vein distention is characteristic o!constrictive pericarditis, #"t does not

"s"ally occ"r +ith mitral stenosis.

he"matic heart disease "s"ally has t+ovalves involved, the aortic and the mitral.

This is not so +ith constrictive

pericarditis.

Coarctation o! the Aorta


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The diagnosis o! coarctation o! the aortacan generally #e made #y several simple

!indings: Hypertension in the "pper arms, a #asal

systolic m"rm"r, and decreased or a#sent

!emoral arterial p"lsations.

Continuous "ur#urs


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All that is continuous is not patentductus.

Dr. illiam 0elson o! the $niversity o!

-o"th Carolina has a list o! the possi#le

ca"ses o! contin"o"s m"rm"rs: Patent d"ct"s arterios"s

Aortic p"lmonic +indo+

Tr"nc"s 6*66*666

Anomalo"s origin o! le!t coronary artery !rom

the p"lmonary artery

Continuous "ur#urs

Accessory coronary artery


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y y y -in"s o! Falsalva !ist"la Coronary arterial !ist"la -ystemic arterioveno"s !ist"la

Blaloc1*Ta"ssig operation Potts operation aterson operation Coarctation o! the aorta

Coarctation o! the p"lmonary artery P"lmonary Throm#oem#olism

Continuous "ur#urs *Arteritis *Arteriosclerosis o#literans


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*Coronary ;stenosis= *Feno"s h"m*nec1 *Mammary h"m J #reast pregnancy2 *Total anomalo"s p"lmonary veno"s connection *Coarctation collaterals *Bronchial collaterals *Tr"c"s*6F *;Pse"do*tr"nc"s= *Tric"spid atresia *-evere Tetralogy o! allot *Cr"veiller*Ba"mgarten -yndrome


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Continuous "ur#urs


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6t !re%"ently has the character o! acontin"o"s lo"d, lo+ !re%"ency roaring

m"rm"r, and it "s"ally can #e made to

disappear #y moving the head to the

!or+ard position.

Light press"re +ith the !inger over the

"pper part o! the "g"lar vein +ill ca"se

the m"rm"r to cease.


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S3and S;


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$lectrocardiography 0ormal Fariants: The a#sence o! an -9 or

-8 gallop may #e help!"l in eval"ation o! a

patient +ho has !indings on the (C)

s"spicio"s !or coronary artery disease,

myocarditis, or cardiomyopathy.

Prosthetic 'alves


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M"ltiple -ystolic -o"nds J ollo+ing avalve replacement "tiliing the -tarr*

(d+ards #all valve, n"mero"s systolic

so"nds can #e heard +hich might

sim"late the rolling o! dice on a hard

s"r!ace or the !lipping o! a stic1 on a pic1et

!ence.


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Holosystolic "ur#urs

Th ! t i l t l d ! t i


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The m"rm"r o! ventric"lar septal de!ect is"s"ally #est heard along the lo+er le!tsternal #order, altho"gh there is radiationo! this m"rm"r to the ape&.

The papillary m"scle r"pt"re is more li1elyto have the m"rm"r lo"dest at the ape&,+ith radiation laterally to the le!t a&illarylines.

Be s"re to care!"lly search !or a palpa#lethrill, !or this may clinch the diagnosis.


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Pul#onary Hypertension

-i ! l h t i i l d


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-igns o! p"lmonary hypertension incl"de: A right ventric"lar li!ting imp"lse along the

lo+er le!t sternal #order4

A palpa#le p"lmonic valve clos"re4

Possi#ly an A*+ave detected on e&amination

o! the "g"lar veno"s p"lse in the nec1.


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Pul#onary Hypertension

- D t P i P l


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-yncope D"e to Primary P"lmonaryHypertensionAny time a yo"ng +oman has episodes o!

syncope al+ays thing o! primary p"lmonary

hypertension.

rom:

C di P l # P t H


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Cardiac Pearls #y . Proctor Harvey Cardiovasc"lar Medicine Fol"me 7 #y (ric

Topol

$p to Date 7>>9 H"rst

cardiac clinical examination

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