DOCSLIB.ORG

Does This Patient Have Aortic Regurgitation?

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Does This Patient Have Aortic Regurgitation? THE RATIONAL CLINICAL EXAMINATION Does This Patient Have Aortic Regurgitation? Niteesh K. Choudhry, MD Objective To review evidence as to the precision and accuracy of clinical examina- Edward E. Etchells, MD, MSc tion for aortic regurgitation (AR). Methods We conducted a structured MEDLINE search of English-language articles CLINICAL SCENARIO (January 1966-July 1997), manually reviewed all reference lists of potentially relevant You are asked to see a 59-year-old articles, and contacted authors of relevant studies for additional information. Each study woman with liver cirrhosis who will be (n = 16) was independently reviewed by both authors and graded for methodological undergoing sclerotherapy for esopha- quality. geal varices. When she was examined by Results Most studies assessed cardiologists as examiners. Cardiologists’ precision for her primary care physician, she had a detecting diastolic murmurs was moderate using audiotapes (k = 0.51) and was good pulse pressure of 70 mm Hg. The pri- in the clinical setting (simple agreement, 94%). The most useful finding for ruling in mary care physician is concerned about AR is the presence of an early diastolic murmur (positive likelihood ratio [LR], 8.8- the possibility of aortic regurgitation 32.0 [95% confidence interval {CI}, 2.8-32 to 16-63] for detecting mild or greater AR (AR) and asks you whether endocardi- and 4.0-8.3 [95% CI, 2.5-6.9 to 6.2-11] for detecting moderate or greater AR) (2 tis prophylaxis is necessary for sclero- grade A studies). The most useful finding for ruling out AR is the absence of early di- astolic murmur (negative LR, 0.2-0.3 [95% CI, 0.1-0.3 to 0.2-0.4) for mild or greater therapy. You conduct a complete physi- AR and 0.1 [95% CI, 0.0-0.3] for moderate or greater AR) (2 grade A studies). Except cal examination and hear no early for a test evaluating the response to transient arterial occlusion (positive LR, 8.4 [95% diastolic murmur in the third or fourth CI, 1.3-81.0]; negative LR, 0.3 [95% CI, 0.1-0.8]), most signs display poor sensitivity intercostal spaces at the left-sternal bor- and specificity for AR. der. You feel that the patient is unlikely Conclusion Clinical examination by cardiologists is accurate for detecting AR, but to have AR and that endocarditis pro- not enough is known about the examinations of less-expert clinicians. phylaxis is not needed. You suspect that JAMA. 1999;281:2231-2238 www.jama.com the wide pulse pressure is a peripheral hemodynamic consequence of cirrho- creased in recent years. It is estimated ing blood viscosity, blood flow veloc- sis, not AR. The primary care physi- that 2% of the general population un- ity and turbulence, the distance between cian, however, wonders whether the pro- dergoes noninvasive cardiac diagnos- the vibrations and the stethoscope, the cedure should be delayed until an tic evaluation annually.3 If a careful angle at which the vibrations meet the echocardiogram can be obtained. clinical examination can exclude the stethoscope, the transmission quali- presence of AR, then there would be no ties of the tissue between the vibra- WHY IS THE CLINICAL need to proceed with further cardiac tion and the stethoscope, and the au- EXAMINATION IMPORTANT evaluation. ditory capabilities of the examiner.5 IN EVALUATING FOR AR? Aortic regurgitation is a potentially se- Anatomical and Physiological How to Examine for AR rious cardiac abnormality that may be Origins of Diastolic Murmurs A complete clinical history and physi- caused by important underlying disor- The cardinal manifestation of AR is a cal examination are essential in the ders. Patients with AR require careful diastolic murmur. Diastolic murmurs Author Affiliations: Division of General Internal Medi- clinical monitoring to identify the op- are important indicators of structural cine and Clinical Epidemiology, Department of Medi- timal time for surgical intervention. cardiac abnormalities or pathological cine, University of Toronto and the University Health Asymptomatic patients with severe AR states of increased flow (TABLE 1). As Network, Toronto, Ontario. 1 Corresponding Author: Edward E. Etchells, MD, MSc, may benefit from vasodilator therapy. discussed in a previous article in this University Health Network, 200 Elizabeth St, eng- Endocarditis prophylaxis may be indi- series,4 heart murmurs are produced 248, Toronto, Ontario, Canada M5G 2C4 (e-mail: [email protected]). cated for patients with AR who are un- when turbulent blood flow causes pro- The Rational Clinical Examination Section Editors: dergoing various procedures.2 longed auditory vibrations of cardiac David L. Simel, MD, MHS, Durham Veterans Affairs Medical Center and Duke University Medical Center, The use of noninvasive cardiac test- structures. The intensity of the mur- Durham, NC; Drummond Rennie, MD, Deputy Edi- ing, such as echocardiography, has in- mur depends on many factors, includ- tor (West), JAMA. ©1999 American Medical Association. All rights reserved. JAMA, June 16, 1999—Vol 281, No. 23 2231 Downloaded from www.jama.com at University of Florida, on August 11, 2005 AORTIC REGURGITATION evaluation of patients with a diastolic The precision and accuracy of many systolic murmurs but may also be used murmur. A diastolic murmur in a pa- individual components of the examina- to describe diastolic murmurs. A grade tient with renal failure and volume over- tion for AR, including all of the cardiac 1 murmur is not heard immediately on load will have different significance than history and most of the physical exami- auscultation, but is heard after the ex- a diastolic murmur in a patient with a nation, have not been adequately evalu- aminer focuses for a few seconds. Grade history of rheumatic fever and atrial fi- ated. This article will focus on aspects 2 murmurs are heard immediately on brillation. of the cardiac physical examination that auscultation but are softer than the loud The examiner’s ability to detect a di- have been sufficiently assessed for pre- grade 3. Grade 4 murmurs are associ- astolic murmur can be undermined by cision or accuracy. ated with a palpable precordial vibra- environmental factors such as noisy tion called a thrill. (Grade 5 and 6 mur- rooms, examiner factors such as fa- Cardiac Auscultation murs are also associated with a thrill. A tigue or haste, and patient factors such During routine auscultation, the ex- grade 5 murmur is audible when only as dyspnea or tachycardia.6 If examin- aminer attempts to detect a diastolic 1 edge of the stethoscope is on the chest, ing conditions are not optimal, the ex- murmur. Diastole is the period that be- and a grade 6 murmur is audible with amination should be repeated when gins with the closure of the aortic and the entire stethoscope lifted off the conditions improve. pulmonic valves (second heart sound chest.) [S2]) and ends with the closure of the The typical murmur of AR is an early mitral and tricuspid valves (first heart Table 1. Selected Causes of Diastolic diastolic, decrescendo blowing sound Murmurs sound [S1]). A common maneuver used (Figure 2), which may be accentuated to identify diastole is to palpate the ca- Abnormal cardiac structure with the patient sitting upright and lean- Aortic regurgitation rotid artery pulse during auscultation; 9 ing forward. In some cases, S2 can be Mitral stenosis S is synchronous with the carotid ar- Pulmonic regurgitation 1 obscured by the murmur. Most AR mur- Tricuspid stenosis tery pulsation while S2 follows the pulse. murs are high pitched and are best heard Atrial myxoma A diastolic murmur is a diastolic sound Ventricular septal defect* with the diaphragm of the stethoscope Atrial septal defect* longer than a heart sound. Examiners placed firmly on the chest wall. Some AR Mitral regurgitation* should describe the grade, location of murmurs are low pitched and are bet- Normal cardiac structure, increased flow IGURE Renal failure with volume overload maximal intensity (F 1), timing ter heard with the bell of the stetho- Thyrotoxicosis (FIGURE 2), duration, pitch, and radia- scope placed lightly on the chest wall. Anemia tion of the murmur. Sepsis For example, the AR murmur associ- The Levine grading system,7 with Diastolic murmurs are caused by abnormally increased ated with endocarditis and a fenes- * 8 diastolic flow across the mitral or tricuspid valves. slight modifications, was developed for trated aortic valve can be low pitched. The examiner should apply the stetho- Figure 1. Typical Location of Abnormal Diastolic Murmurs scope to the chest wall in the third or Figure 2. Selected Features of Diastolic Murmors 1 S S 2 2 1 S2 OS S1 Diastolic murmurs are classified based on the time of 15 3 onset of the murmur. An early diastolic murmur be- gins with the second heart sound (S2). Top, Early di- astolic murmurs typically decrease in intensity (decre- scendo) and disappear before the first heart sound (S1). In some cases, an early diastolic murmur can con- There are 3 important areas to auscultate for diastolic murmurs. Area 1 is the second and third intercostal spaces tinue through diastole. Bottom, A mid-diastolic mur- at the right-sternal border. Area 2 is the second and fourth intercostal spaces at the left-sternal border. Aortic mur begins clearly after S2 (in mitral stenosis, classi- regurgitation murmurs may be heard in both areas 1 and 2. If the murmur is loudest in area 1, then the un- cally after an opening snap [OS]). A late diastolic (or derlying cause of aortic regurgitation may be an ascending aortic aneurysm or aortic dissection. Pulmonic re- presystolic) murmur begins in the interval immedi- gurgitation murmurs are loudest in the superior part of area 2, and may radiate downward. The murmur of ately before S1.
Load more

Recommended publications
  • Heart Murmurs
    HEART MURMURS PART I BY WILLIAM EVANS From the Cardiac Department of the London Hospital Received November 5, 1946 Auscultation of the heart, depending as it does on the acuity of the auditory sense and providing information commensurate with the observer's experience, cannot always determine unequivocally the various sound effects that may take place during systole and diastole. It is not surprising, therefore, that auscultation tied to traditional theories may sometimes lead to a wrong interpretation of the condition, although a judgment born of ripe experience in clinical medicine and pathology will avoid serious mistakes. It is more than fortuitous that modern auscultation has grown on such a secure foundation, but it is imperative that for the solution of outstanding problems there should be precise means of registering heart sounds. This is why a phonocardiogram was included in the examination of a series of patients pre- senting murmurs. As each patient attended for the test, the signs elicited on clinical auscultation were first noted and an opinion was formed on their significance. Cardioscopy was invariably carried out, and, when necessary, teleradiograms were taken. Limb and chest lead electrocardiograms were frequently recorded in addition to the lead selected as a control for the phonocardiogram. Many cases came to necropsy. The simultaneous electrocardiogram and sound record was taken by a double string galvanometer supplied by the Cambridge Instrument Company, and the length of the connecting tube leading from the chest to the amplifier was 46 cm. Although the amplitude of sounds and murmurs was matched against each other in individual patients, there was no attempt to standardize the intensity of murmurs in terms of amplitude in different patients; in fact it was varied deliberately in order to produce such excursion of the recording fibre as would best show the murmur.
    [Show full text]
  • Does This Patient Have Aortic Regurgitation?
    THE RATIONAL CLINICAL EXAMINATION Does This Patient Have Aortic Regurgitation? Niteesh K. Choudhry, MD Objective To review evidence as to the precision and accuracy of clinical examina- Edward E. Etchells, MD, MSc tion for aortic regurgitation (AR). Methods We conducted a structured MEDLINE search of English-language articles CLINICAL SCENARIO (January 1966-July 1997), manually reviewed all reference lists of potentially relevant You are asked to see a 59-year-old articles, and contacted authors of relevant studies for additional information. Each study woman with liver cirrhosis who will be (n = 16) was independently reviewed by both authors and graded for methodological undergoing sclerotherapy for esopha- quality. geal varices. When she was examined by Results Most studies assessed cardiologists as examiners. Cardiologists’ precision for her primary care physician, she had a detecting diastolic murmurs was moderate using audiotapes (k = 0.51) and was good pulse pressure of 70 mm Hg. The pri- in the clinical setting (simple agreement, 94%). The most useful finding for ruling in mary care physician is concerned about AR is the presence of an early diastolic murmur (positive likelihood ratio [LR], 8.8- the possibility of aortic regurgitation 32.0 [95% confidence interval {CI}, 2.8-32 to 16-63] for detecting mild or greater AR (AR) and asks you whether endocardi- and 4.0-8.3 [95% CI, 2.5-6.9 to 6.2-11] for detecting moderate or greater AR) (2 tis prophylaxis is necessary for sclero- grade A studies). The most useful finding for ruling out AR is the absence of early di- astolic murmur (negative LR, 0.2-0.3 [95% CI, 0.1-0.3 to 0.2-0.4) for mild or greater therapy.
    [Show full text]
  • Viding Diagnostic Insights Into the Pathophysiologic Mechanisms
    viding diagnostic insights into the pathophysiologic mechanisms under- lying the acoustic findings heard in clinical practice.162-165 Contemporary physicians should take advantage of the valuable clinical information that can be obtained by such an inexpensive instrument and expedient and reli- able tool as the stethoscope. The following section reviews the funda- mental technique of cardiac auscultation, emphasizing the diagnostic value and practical clinical applications of this time-honored (but endan- gered) art in this time of need.166 The Art and Technique of Cardiac Auscultation. Auscultation of the heart and vascular system is one of the most challenging and rewarding clinical diagnostic skills that can (and should) be learned and applied by every prac- ticing physician. Proficiency in cardiac auscultation requires experience, repeated practice, and a great deal of patience (and patients). Most impor- tantly, it requires a proper state of mind. (“we hear what we listen for”). Although the most vital component of the auscultatory apparatus lies between the earpieces, the proper use of a well-designed, efficient stetho- scope cannot be overemphasized. To ensure optimal sound transmission, the well-crafted stethoscope should be airtight, with snug but comfortably-fit- ting earpieces, properly aligned metal binaurals, and flexible, double-barrel, 1 thick-walled tubing, ⁄8 inch in internal diameter and no more than 12 to 15 inches in length. A high-quality stethoscope should be equipped with both bell and diaphragm chest pieces. The bell, when applied gently to the skin, will “bring out” low frequency sounds and murmurs (eg, faint S4 or S3 gal- lop or diastolic rumble) and the diaphragm, when pressed firmly against the skin, will accentuate high-pitched acoustic events (eg, diastolic blowing murmur of AR).
    [Show full text]
  • Kuban State Medical University" of the Ministry of Healthcare of the Russian Federation
    Federal State Budgetary Educational Institution of Higher Education «Kuban State Medical University" of the Ministry of Healthcare of the Russian Federation. ФЕДЕРАЛЬНОЕ ГОСУДАРСТВЕННОЕ БЮДЖЕТНОЕ ОБРАЗОВАТЕЛЬНОЕ УЧРЕЖДЕНИЕ ВЫСШЕГО ОБРАЗОВАНИЯ «КУБАНСКИЙ ГОСУДАРСТВЕННЫЙ МЕДИЦИНСКИЙ УНИВЕРСИТЕТ» МИНИСТЕРСТВА ЗДРАВООХРАНЕНИЯ РОССИЙСКОЙ ФЕДЕРАЦИИ (ФГБОУ ВО КубГМУ Минздрава России) Кафедра пропедевтики внутренних болезней Department of Propaedeutics of Internal Diseases BASIC CLINICAL SYNDROMES Guidelines for students of foreign (English) students of the 3rd year of medical university Krasnodar 2020 2 УДК 616-07:616-072 ББК 53.4 Compiled by the staff of the department of propaedeutics of internal diseases Federal State Budgetary Educational Institution of Higher Education «Kuban State Medical University" of the Ministry of Healthcare of the Russian Federation: assistant, candidate of medical sciences M.I. Bocharnikova; docent, c.m.s. I.V. Kryuchkova; assistent E.A. Kuznetsova; assistent, c.m.s. A.T. Nepso; assistent YU.A. Solodova; assistent D.I. Panchenko; docent, c.m.s. O.A. Shevchenko. Edited by the head of the department of propaedeutics of internal diseases FSBEI HE KubSMU of the Ministry of Healthcare of the Russian Federation docent A.Yu. Ionov. Guidelines "The main clinical syndromes." - Krasnodar, FSBEI HE KubSMU of the Ministry of Healthcare of the Russian Federation, 2019. – 120 p. Reviewers: Head of the Department of Faculty Therapy, FSBEI HE KubSMU of the Ministry of Health of Russia Professor L.N. Eliseeva Head of the Department
    [Show full text]
  • Mitral Valvotomy in the Younger Age-Groups
    2 Julie 1955 S.A. TYDSKRIF VIR GF.NEESKUNDE 639 15. Veenboer, W. H. and Kooistra, H. P. (1947): Amer. J. 21. Schauta quoted by Phaneuf, L. E. (1949): Surg. Gynec. Obstet. Gynec., 53, 936. Obstet., 89; 92. 16. Danforth, W. C. and Reynolds, R. A. (1948): Anat. Bull. 22. Bastiaanse, M. A. v.B. (1952): J. Obstet. Gynaec. Brit. Emp., Northw. Univ. Med. Sch., 22, 232. 59, 61 I. 17. Cadenhead, E. F. (1951): J. Int. Coil. Surg., 15, 57. 23. Heyman, J., Rentewall, O. and Benner, S. (1941): Acta radiol., 22, I I. 18. Arthure, H. S. E. (1949): Proc. Roy. Soc. Med., 42, 388. 24. Eastman, O. N. (1948): N.Y.St. J. Med., 48, 49. 19. Shaw, W. E- (1950): Modem Trends in Obstetrics and Gynae­ 25. CampbeJl, Z. B. (1946): Amer. J. Obstet. Gynec., 52, 598. cology, p. 648. London: Butterworth. 26. Waugh, John M. (1943): J. iodiana Med. Assoc., 36, 537. 20. Te Linde, W. and Richardson, E. H. (1943): Amer. J. Obstet. 27. Werner, Paul (1929 and 1931): Surg. Gynec. Obstet., 49, Gynec., 45, 29. 363, and 52, 233. MITRAL VALVOTOMY IN THE YOUNGER AGE-GROUPS BERTRAM A. BRADWW, M.D. (RAND), M.R.C.P., M.R.C.P.E. Al'lD G. R. CRAWSHAW, M.D. (VICT.), F.R.C.S. Johannesburg Mitral stenosis represents an end stage of rheumatic carditis. it takes 5-15 years to develop after the onset of the initial attack, and usually occurs during the 2nd or 3rd 5-year period after the initial attack.s Thus the occurrence of tight mitral stenosis of a type suitable for operation is unusual unaer the age of 16 years.
    [Show full text]
  • Southern Medical and Surgical Journal
    "; SOUTHERN MEDICAL AND SUBGICAL JOURNAL. Vol. XL] SEW SERIES.—AUGUST, 1S55. [No. 8. ORIGINAL AND ECLECTIC. ARTICLE XXI. Notes on the Epidemic Fever of 1854. By P. M. Kollock, M. D., Professor of Obstetrics in " the Savannah Medical College." Savannah, August 11th, 1854. The weather during the last month (July) has been intensely hot—I have never suffered so much from heat in my life ; the ther- mometer, in the shade, rose repeatedly to 94° in my library, where, in ordinary seasons, it has rarely attained a more elevated point than 86°. During this time we have had very little rain. Within the last week or ten days there have been cases of coup de soleiL and we now have cases of fever, terminating in black dis- charges from the stomach, of a " coffee ground " character. Up to this time (Aug. 11), some six cases have occurred—four of these in the " Savannah Poor House and Hospital." One case oc- curred in the female ward, (of which I have charge.) in a young Irish girl, who came in with fever, for which she was treated with calomel and quinine, having been purged previous to her entrance. She complained of headache and thirst ; no tenderness of epigastri- um ; skin diy pulse frequent ; tongue slightly furred. ; Five or six grains of quinine (which had been administered on her entrance) were repeated, combined with two grains of calomel, in twelve hours. In eighteen hours after, she discharged fc coffee ground matter from her stomach, and died before I saw her again. No autopsy.
    [Show full text]
  • Triple Heart Rhythm*
    TRIPLE HEART RHYTHM * BY WILLIAM EVANS From the Cardiac Department of The London Hospital Received August 28, 1943 Triple heart rhythm stands for the cadence produced when three sounds recur in successive cardiac cycles, just as two sounds compose the familiar dual rhythm of cardiac auscultation, and more rarely, four sounds a quadruple rhythm. The conflicting views on the subject have long served to discourage attempts at a clinical perception of the problem. Disagreement is perhaps best illustrated by recounting the varied terminology employed to describe it. Thus we have gallop rhythm, canter rhythm, and trot rhythm; presystolic gallop, systolic gallop, protodiastolic gallop, and mesodiastolic gallop; complete summation gallop and incomplete summation gallop; auricular gallop, ventricular gallop, and auriculo-ventricular gallop; true gallop; left-sided gallop and right-sided gallop; rapid-filling gallop; diastolic echo; mitral opening snap; reduplication of first sound and reduplication of second sound; Potain's murmur; third heart sound and fourth heart sound. Others may have escaped my notice. This muddled nomenclature, as long as it stands, will frustrate any attempt to unify the many views held on triple rhythm. There is need of a simplified terminology based on clinical findings. It is indeed clear that a neglect of the clinical aspect on the one hand, and a persistence on the part ofmany to explain the mechanism of the supernumerary sound on the other hand, and to classify triple rhythm in accordance with sound records, have been largely responsible for obscuring this common form of cardiac rhythm. Phonocardiography need not become a routine test in clinical cardiology; when it has helped to establish a classification of triple rhythm it will have achieved its main purpose, though it will still serve in other auscultatory problems.
    [Show full text]
  • Cardiac Auscultation: Rediscovering the Lost Art Michael A
    Cardiac Auscultation: Rediscovering the Lost Art Michael A. Chizner, MD Abstract: Cardiac auscultation, long considered the center- piece of the cardiac clinical examination, is rapidly becoming a lost art. Inadequate emphasis on the essentials of cardiac auscultation has resulted from the widespread availability of more elaborate and expensive “high-tech” diagnostic and therapeutic methods, particularly Doppler echocardiogra- phy. However, sophisticated high technology is not a substi- tute for a solid foundation in clinical cardiology including cardiac auscultation. When used properly, the stethoscope remains a valuable and cost-effective clinical tool that often enables many well-trained and experienced cardiac auscul- tators to make a rapid and accurate cardiac diagnosis with fewer, if any, additional studies. Not every patient needs every test. Accordingly, this monograph reviews the fundamental principles of the art of cardiac auscultation. Emphasis is placed on the proper use of the stethoscope and the diagnos- tic and prognostic significance of the myriad heart sounds and murmurs present in patients with and without symp- tomatic heart disease. A practical clinical overview of the common auscultatory findings encountered in a variety of cardiac disease states and conditions will also be discussed. This monograph will inspire many practitioners to pick up their stethoscope, practice their cardiac examination, perfect their auscultatory skills, and reap the rewards of rediscov- ering this time-honored method of evaluating the cardiovas- cular system. (Curr Probl Cardiol 2008;33:326-408.) espite its long and rich tradition in clinical medicine, the time- honored art of cardiac auscultation is rapidly becoming a lost art. D Most of today’s physicians have a difficult time identifying normal The author has no conflicts of interest to disclose.
    [Show full text]
  • Mitral Stenosis
    Valvular heart diseases METHODIC MATERIALS FOR INTERNATIONAL STUDENTS (IV-VI year) Author: N.A.Filippova, assistant professor Published: 2004 Valvular heart disease with mitral valve affection Normal mitral valve Anatomy The normal mitral valve is a complex structure, consisting of leaflets, annulus, chordae tendineae, and papillary muscles. Its anatomy as studied at autopsy shows an unusual degree of variation between normal subjects. Of the two leaflets, the anterior one is the larger, both from base to margin, and also in its perimeter. It is attached to the root of the aorta and the membranous septum at the base of the heart, and is continuous with the chordae peripherally. It thus passes across the centre of the left ventricular cavity, dividing the inlet from the outlet portion. The posterior cusp is attached to the mitral ring and to the anterior cusp at both commissures. It is continuous with the posterior wall of the left atrium, and is divided into three portions by two scallops. The chordae arise from the ventricular margins of both cusps, and are inserted into the heads of the papillary muscles. There are multiple subdivisions in the chordae as they pass from papillary muscles to the cusps, which form an effective secondary pathway, additional to the main one between the cusps, for blood to enter the ventricle. There are two papillary muscles, one anteromedial and the other posterolateral. In general, the former is larger, and has a more uniform structure than the latter which may be double. Both may have up to six heads, giving rise to chordae.
    [Show full text]
  • CHAPTER E13 Approach to the Patient with a Heart Murmur
    S1 S2 CHAPTER e13 A Approach to the Patient With a Heart Murmur B Patrick T. O’Gara C Joseph Loscalzo CHAPTER e13 A2 P2 D Ⅵ INTRODUCTION The differential diagnosis of a heart murmur begins with a careful assessment of its major attributes and response to bedside maneu- vers. The history, clinical context, and associated physical examina- E tion findings provide additional clues by which the significance of a heart murmur is established. Accurate bedside identification of a OS Approach to the Patient With a Heart Murmur heart murmur can inform decisions regarding the indications for F noninvasive testing and the need for referral to a cardiovascular specialist. Preliminary discussions can be held with the patient regarding antibiotic or rheumatic fever prophylaxis, the need to S3 restrict various forms of physical activity, and the potential role for G family screening. Heart murmurs are caused by audible vibrations that are due to increased turbulence from accelerated blood flow through normal or abnormal orifices, flow through a narrowed or irregular orifice H into a dilated vessel or chamber, or backward flow through an incompetent valve, ventricular septal defect, or patent ductus arte- Figure e13-1 Diagram depicting principal heart murmurs. riosus. They traditionally are defined in terms of their timing within A. Presystolic murmur of mitral or tricuspid stenosis. B. Holosystolic (pansystolic) the cardiac cycle ( Fig. e13-1 ) . Systolic murmurs begin with or after murmur of mitral or tricuspid regurgitation or of ventricular septal defect. the first heart sound (S1 ) and terminate at or before the component C. Aortic ejection murmur beginning with an ejection click and fading (A2 or P2 ) of the second heart sound (S2 ) that corresponds to their before the second heart sound.
    [Show full text]
  • Rheumatic Fever in Young Adults by Walter T
    Br Heart J: first published as 10.1136/hrt.14.1.70 on 1 January 1952. Downloaded from 1 RHEUMATIC FEVER IN YOUNG ADULTS BY WALTER T. ZIMDAHL From the Cardiovascular Service, The Brooke General Hospital, Brook Army Medical Centre, Fort Sam Houston, Texas Received September 1, 1950 During and immediately following World War II the opportunity presented itself to observe numerous cases of rheumatic fever in young adults. The present study was undertaken from patients admitted to the Brooke General Hospital over a period of one year. There were four hundred patients admitted for rheumatic fever during this time. Observation of each patient included the history, physical examination with special attention to the heart, complete blood count, examination of urine and stools, sedimentation rate, electrocardiogram, X-ray, and fluoro- scopic examination. The diagnosis was based on these findings. Only if at least one major manifes- tation such as polyarthritis, carditis, chorea, old history of rheumatic fever, or nodules was present with several ofthe minor ones, such as fever, rash, epistaxis, leucocytosis, elevated sedimentation rate, and anmmia was the diagnosis made. Two hundred and two of these patients, all enlisted personnel of the Army, were diagnosed as having rheumatic fever, and were followed for several months, the average stay in the hospital being six months. Many have been observed for one year or more before discharge. CLINICAL FEATURES http://heart.bmj.com/ Age ofPatients. The patients' ages ranged from 17-39 years; the largest groups were 18 years with 65, and 19 years with 63 patients. Between the ages of 17-20 there were 166 (82%); be- tween the ages of 21-29 there were 29 (14%) and from the ages of 30-39 there were 7 (3%).
    [Show full text]
  • A Haemodynamic Correlation
    Br Heart J: first published as 10.1136/hrt.33.1.16 on 1 January 1971. Downloaded from British Heart journal, I97I, 33, I6-3I. Rheumatic tricuspid stenosis A haemodynamic correlation Nabil El-Sherif From the Cardiology Department, Faculty of Medicine, Cairo University, Cairo, Egypt, U.A.R. Studies were made on 2I cases with haemodynamically significant tricuspid stenosis, including I2 in sinus rhythm and 9 with atrialfibrillation. A remarkable degree of correlation was found be- tween the haemodynamic changes and the physical signs, particularly auscultation and left para- sternalpulsations represented by the right ventricular apex cardiogram. Inspiratory augmentation of the tricuspid diastolic murmur was always evident, while tricuspid systolic murmur either decreased appreciably or showed little change. This sign was considered essentialfor the diagnosis of dominant stenosis, especially in the presence of atrialfibrillation - where a systolic murmur is nearly always associated - and it reflected a characteristic haemodynamic response to inspiration showing a concomitant increase of right atrial/right ventricular diastolic gradient and decrease of right ventricular/right atrial systolic gradient. A tricuspid opening snap was recorded in half the cases. This was mainly facilitated by the simultaneous recording of both right and left apex cardiograms separating a frequently earlier tricuspid snap from a mitral snap. The II-OS (T) interval showed considerable variation with the heart rate and cycle length. The right ventricular apex cardiogram was introduced as a valuable aid in the diagnosis of dominant stenosis, especially in the presence of atrialfibrillation where it showed absence of a rapidfilling wave. In patients with sinus rhythm, the right ventricular apex cardiogram showed a prominent a wave which represented direct right atrial tracing.
    [Show full text]