Cardiovascular Physical Exam: Putting Your Finger on the Pulse

Eddie Needham, MD, FAAFP

ACTIVITY DISCLAIMER

The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

1 DISCLOSURE

It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

Eddie Needham, MD, FAAFP

Program Director and Academic Chairman, Florida Hospital Family Medicine Residency; Associate Professor, University of Central Florida College of Medicine; Clinical Associate Professor, Florida State University College of Medicine

Dr. Needham has been a family medicine educator for 23 years. In 2017, he received the Gold Level Program Director Recognition Award from the Association of Family Medicine Residency Directors (AFMRD) for his years of leadership and experience. He has been a requested speaker at FMX since 2010, as well as speaking for the Georgia and Florida chapters of the AAFP for more than 15 years. Dr. Needham practices full-service family medicine, providing care from “conception to resurrection.” In 2013, he received the Full- Time Florida Family Physician Educator award. He is also the recipient of the 2007 Georgia Academy of Family Physicians Teacher of the Year award and the AAFP Foundation’s 1997 Parke-Davis teaching award. It is his joy and passion to teach students of medicine the wonders of the human body and spirit.

2 Learning Objectives

1. Take a preparticipation sports history using questions that have proven effective for identifying athletes at risk for sudden cardiac death.

2. Recognize symptoms and signs of cardiovascular conditions that may indicate a need for echocardiogram.

3. Distinguish clinical and auscultatory characteristics of physiologic and pathologic cardiac murmurs, and know when further evaluation by echocardiography is indicated.

4. Identify criteria for appropriate use of electrocardiogram (ECG) during the preparticipation sports physical, and explain what ECG findings may be clinically significant for athletes.

5. Understand the role of point-of-care ultrasound to supplement the bedside cardiovascular physical exam.

Audience Engagement System Step 1 Step 2 Step 3

3 More About Eddie Needham, MD, FAAFP

• Practices “conception to resurrection” family medicine • Taught family medicine for two decades • Joy and passion to teach the wonders of the human body and spirit. • Married for 30 years with five grown children • Adventure: • Rigors of triathlons, soccer, and volleyball • Wonder and surprise of fishing • Mountain top experiences with friends

4 5 Le Clinician existe toujours!

• Strive to truly listen to the patient • Demand excellence

The Cardiovascular Exam • Observation • Percussion • Palpation • Auscultation • …reality check?

6 CV Exam case 1 - Observation • 27 yo black male presents with dyspnea, easy fatigueability.

• VS normal except RR 20, Pulse ox 94%RA • Resting in hospital bed • Muscular, fit appearing • Lungs CTA • CV easily observable left parasternal heave • DX: idiopathic pulmonary hypertension

CV exam case 2 - Percussion • …okay, I got nothing for this.  • I have not yet percussed the heart to confirm a diagnose of dextrocardia in a patient. • Tap on clavicle technique of pleural effusion

7 CV exam case 3.1 - Palpation • 43 yo male presents with longstanding poorly controlled HTN. • At admission, BP is 220/120 • Exam notable for a palpable S4 • With treatment of HTN, S4 dissipates overnight • Patient discharged with BP 160-180/100

CV exam case 3.2 - Palpation • 63 yo male presents for a routine follow up of high cholesterol and T2DM (oral meds) • BP noted to be 170/70 • Ddx wide pulse pressure: – Aortic regurgitation, arteriosclerosis, others • Repeat BP by physician – First Korotkoff sounds at 170 and 140. – 170 = PVC; 140 = regular 1st Korotkoff sound

8 CV exam case 4 - Auscultation • Physiologic murmur … AKA normal • Aortic stenosis • Mitral regurgitation • Mitral valve prolapse

Pulses – a comment • Femoral pulse – thrill may suggest atherosclerosis or aortic regurgitation • Distal pulses – posterior tibial and dorsalis pedis – DP absent in up to 10% of normal population – Palpate PT pulse if concerned for PAD • Discrepant brachial BPs – consider coarctation or congenital abnormalities

9 Joe soldier going to work…

CC license at: By Trish Harris - http://www.soc.mil/uns/Photo/2009/album/slides/090422-A-6095H-164.html, Public Domain, https://commons.wikimedia.org/w/index.php?curid=15035668

Why do these conditions matter to Joe Physician?

Anyone perform preparticipation physical exams in their practice?

10 The preparticipation physical exam History elements • Exertional symptoms • Presence of a heart murmur • Symptoms of Marfan’s syndrome • Family history of premature serious cardiac conditions or sudden death

Mirabelli MH, Devine MJ, Singh J, Mendoza M: The preparticipation sports evaluation, Am Fam Physician 2015;92(5):371-376

The preparticipation physical exam Physical exam elements

• Cardiac auscultation supine and standing with Valsalva (HCM) • Femoral pulses (Coarctation) • Assessing for the stigmata of Marfan’s syndrome • Blood pressure at the brachial artery Mirabelli MH, Devine MJ, Singh J, Mendoza M: The preparticipation sports evaluation, Am Fam Physician 2015;92(5):371-376

11 AES Question The condition that leads to the highest morbidity/mortality in Marfan’s Syndrome is: A. Aortic regurgitation B. Coronary artery dissection C. Aortic dissection D. Hypertrophic cardiomyopathy

NBA and MFS • NBA screening prior to draft 2014 • Isaiah Austin – 7’ 1” Baylor Athlete

CC license at: https://commons.wikimedia.org/wiki/File:Isaiah_Austin_2016.jpg

12 Marfan’s Syndrome

• Disorder of fibrillin, resulting in abnormal connective tissue. • Fibrillin 1 gene (FBN1) mutation • 1 in 3000-5000 people in US. • Autosomal dominant transmission • 75% cases are inherited: 25% new mutation

Marfan’s Syndrome Common Physical Exam Findings • Aortic disease – Aneurysmal dilatation, regurgitation, dissection • Ocular disease • Skeletal disease

13 What do you see?

An Aortic Aneurysm

14 MFS CV disease - How to track • At initial Dx – Echo – Confirm measurements with CT or MRI • Remeasure at 6 months to confirm and assess stability • Annual echo to confirm stability, measure progression

MFS CV disease

• Of patients < 40 years old with dissection – 50% had MFS • Only 2% of older patients with aortic dissection had MFS • Only 0.25 – 2% of patients with MVP have MFS

Weyman AE, Scherrer-Crosbie M, Marfan syndrome and mitral valve prolapse, J Clin Invest. 2004 Dec 1; 114(11): 1543–1546.

15 ABFM CKSA questions

AES Question Which of the following murmurs is most consistent with aortic regurgitation? S1 S2 S1 S2 A.| | | | B. | | | | C. | | | |

16 Two conditions that vary with squat to stand: • MVP – Mitral valve prolapse – When patient squats, click and MR murmur move later in systole – When patient stands up, click and MR murmur move earlier in systole • HCM – Hypertrophic cardiomyopathy – When patient squats, murmur gets softer – more blood in LV – When patient stands, murmur gets louder – less blood in LV

It’s about the waves

17 Now I’m here

18 Common mistakes in auscultation • Minimize ambient noise • Remove the patient’s shirt (hair?) • Push firmly with the stethoscope – If you left a ring on the skin, you pushed hard enough • Take the time to listen well • Use provocative maneuvers (squat to stand)

Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. Journal of the American College of Cardiology Volume 63, Issue 22, June 2014 Guideline at: http://www.onlinejacc.org/content/accj/63/22/e57.full.pdf?_ga=2.117599177.1523384412.1523455157-1654496124.1487167180

19 Valvular Heart Disease (VHD) • VHD contributes to more than 40,000 patient deaths and 100,000 operations annually. • Last update to ACC/AHA VHD guidelines was 2014 with focused update in 2017. • VHD accounts for 10-20% of all cardiac procedures in the United States.

Creative commons license at: http://en.wikipedia.org/wiki/File:Diagram_of_the_human_heart_(cropped).svg

20 Valvular Heart Disease (VHD)

• The presence of symptoms in the medical history helps determine the need for surgery • Valvular stenosis obstructs forward flow • Valvular regurgitation permits backward flow • Aortic and mitral valves are most commonly affected

Grading of murmurs

• Grade I/VI Barely discernable • Grade II/VI Readily discernable • Grade III/VI Loud and easily heard • Grade IV/VI Palpable thrill associated with murmur (case) • Grade V/VI Palpable with edge of stethoscope on precordium • Grade VI/VI Heard with stethoscope off chest (case)

21 Valvular Heart Disease (VHD) • Pathologic murmurs requiring evaluation – Any murmur in diastole – Any murmur III/VI or louder – Any murmur in late systole – Murmurs that fall into diagnostic concern • Hypertrophic cardiomyopathy (HCM/IHSS) • A soft systolic murmur can still be concerning – I/VI early diastolic murmur of aortic regurgitation

Busy practice murmur algorithm

Get an Echo

22 Technology • In general, a transthoracic echocardiogram is the first step in evaluating a new cardiac murmur. • Echo’s can also generate revenue for a busy practice • New/emerging technologies include: – Real-time 3D echocardiography (MV pathology) – Cardiac MRI (excellent general applications but issues of access and expense limit use) – Handheld echocardiography

Cardiac Murmur

Systolic Diastolic Continuous

Midsystolic Early systolic or Venous hum, Grade 2 or less Midsystolic – Mammary souffle grade 3 or more; of pregnancy Late systolic, or Asymptomatic Symptomatic Holosystolic and no or other signs associated of cardiac No further findings disease evaluation

No further Echocardiography evaluation

Cardiac catheterization and angiography if appropriate

Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006, Guidelines for the management of patients with valvular heart disease. J Am Coll Cardiol,. 2008; 52(13):e1-142

23 Reality check 

Electronic stethoscope

Creative commons license at: http://commons.wikimedia.org/wiki/File:Electronic_stethoscope.jpg

Auscultatory Excellence Systolic Murmurs

Murmur Quality Location Other findings Aortic stenosis Crescendo-decrescendo 2nd right ICS Delayed carotid upstroke

Harsh, medium pitch Radiates to carotid Soft A2 (late in course) Paradoxical S2 splitting

Mitral regurgitation Mid to late crescendo Apex S3 Holosystolic Radiation to axilla Midsystolic click with MVP Medium to high pitch

nd Pulmonary stenosis Crescendo-decrescendo 2 left ICS Soft P2 Louder with inspiration Holosystolic Tricuspid regurgitation Medium to high pitch Lower left sternal border Large v waves in jugular Louder with inspiration venous pulsations

24 Auscultatory Excellence Diastolic Murmurs

Murmur Quality Location Other findings Aortic regurgitation Decrescendo Lower left sternal brdr Wide pulse pressure High pitched blow Leaning forward Other clinical findings Apex Quincke’s pulses ,etc…

Mitral stenosis Low pitched rumble Apex Opening snap may be Crescendo- Left lateral decubitus present

decrescendo Possible loud P2

Pulmonary regurgitation Decrescendo 2nd left ICS Louder with inspiration

Tricuspid stenosis Low pitched rumble Left sternal border Louder with inspiration

Heart sounds common in FM • Split S2 – physiologic vs fixed • Split S2 vs S3 • S3 and S4 – volume and pressure overload respectively • Aortic stenosis • Mitral regurgitation • Mitral valve prolapse

25 Heart sounds not as common in FM • Aortic regurgitation • HCM • Ventricular septal defect (VSD) • Right-sided murmurs – vary with inspiration • Rare: – Mitral stenosis with opening snap and mid- diastolic rumble

Heart sounds

• Let’s draw a murmur | <||||> | S1 M S2 • Systolic or Diastolic • Early, mid, late, continuous • Location: • URSB – Aortic valve • ULSB – Pulmonic valve • LLSB – Tricuspid … and aortic valves • Apex – Mitral … and aortic valves

26 AES Question Heart sounds • Here’s the sound: • What does it look like? •S1 S2 S1 S2 A.| | | | B.| | | | C.| | | |

Heart sounds • This is what each of these sounds like:

•S1 S2 S1 S2 •| | | | •| | | | •| | | |

27 Anticipate the murmur • Patient with BP 180/100 x 5 years – Likely to have a thick LV • Possible S4 – Pt with palpable S4 • Possible diastolic HF • Patient with severe COPD, still smoking – Possible pulmonary HTN, listen for: • Fixed split S2, right sided murmurs that change with respiration • Patient with HFrEF and an EF = 15% – Likely to have mitral regurgitation murmur

AES Question An 18 yo high school athlete is referred to your office for passing out while playing soccer. No injury. Happened while running on the field. Is noted to have a 2-3/6 systolic murmur at LLSB. Which of the following is most likely?

A. Supraventricular tachycardia B. Tachy-brady syndrome C. Kawasaki’s disease with coronary aneurysms D. Hypertrophic cardiomyopathy

28 EKG for HCM: LVH voltage Note large Q waves  septal hypertrophy

ECGs and preparticipation PEs

• Insufficient evidence to recommend including ECGs in the preparticipation sports exam • Italy and Israel currently include ECGs • Rates for sudden cardiac death in US studies are 1.06 deaths/100,000 person-years. Less than European studies.

Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. 2007;115(12):1643–1655

29 ECGs and preparticipation PEs • ECG findings in athletes may include: – Increased QRS voltage, appearing as LVH – Left axis deviation – Early repolarization and J point elevation that may be overread as ST segment elevation • In general, ECG findings would overwhelming be false positive results

EKGs of note

30 A 55 yo male Anterior wall MI presents urgently to the ED with crushing, substernal chest pain. His EKG shows:

A 62 yo female presents with onset of nausea and vomiting for 1 hour. What is the Diagnosis?

A. Anterior wall MI B. Pericarditis C. Inferior wall MI D.Septal MI

31 Inferior wall MI

Slow and regular – sinus bradycardia?

32 Complete heart block

CC license at: https://commons.wikimedia.org/wiki/File:Wellens%27_Syndrome.png

33 Wellens syndrome • Associated with critical proximal LAD stenosis • Symmetrical, deep, T wave inversions in the anterior precordial leads (V1 – V3) • First described in 1982

34 Brugada Syndrome • Genetically inherited • Increased risk for SCD • Described in 1992 • Death by V. Fib. • Sodium channelopathy • RBBB with ST elevation in V1-3 CC license at: By J. Heuser JHeuser - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=554687

35 EKG #1 - WPW

36 Point of care ultrasound (POCUS) • Becoming a tool for family physicians • Expensive ultrasound ($35-55K) • Handheld ultrasound ($8-10K) • Newer tech combining cellphone ($2K) • Competency assessments? • Reimbursement?

Follow up Echo – How often?

37 Best Practice Recommendations

• The astute history and physical exam is the foundation for clinical excellence. • All patients with an abnormal cardiac murmur should receive an echocardiogram or referral. • Bedside testing with ECG or POCUS can help refine/confirm the differential diagnosis.

Questions

38 Thank you for your attention

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