Essentials of Bedside Cardiology CONTEMPORARY CARDIOLOGY

CHRISTOPHER P. CANNON, MD SERIES EDITOR

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WITH

A Complete Course in Heart Sounds and Murmurs on CD

SECOND EDITION

Jules Constant, MO, FACC

Clinical Associate Professor of Medicine State University of New York at Buffalo School of Medicine Buffalo, NY

Humana Press *- Totowa, New Jersey © 2003 Humana Press Inc. Softcover reprint of the hardcover 1 st edition 2003 999 Riverview Drive, Suite 208 Totowa, New Jersey 07512 www.humanapress.com All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher. The content and opinions expressed in this book are the sole work of the authors and editors, who have warranted due diligence in the creation and issuance of their work. The publisher, editors, and authors are not responsible for errors or omissions or for any consequences arising from the information or opinions presented in this book and make no warranty, express or implied, with respect to its contents. Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the information published and to describe generally accepted practices. The contributors herein have care• fully checked to ensure that the drug selections and dosages set forth in this text are accurate and in accord with the standards accepted at the time of publication. Notwithstanding, since new research, changes in government regulations, and knowledge from clinical experience relating to drug therapy and drug reactions constantly occur, the reader is advised to check the product information provided by the manufacturer of each drug for any change in dosages or for additional warnings and contraindications. This is of utmost importance when the recommended drug herein is a new or infrequently used drug. It is the responsibility of the treating physician to determine dosages and treatment strategies for individual patients. Further, it is the responsi• bility of the health care provider to ascertain the Food and Drug Administration status of each drug or device used in their clinical practice. The publishers, editors, and authors are not responsible for errors or omissions or for any consequences from the application of the information presented in this book and make no warranty, express or implied, with respect to the contents in this publication. This publication is printed on acid-free paper. ® ANSI Z39.48-1984 (American National Standards Institute) Permanence of Paper for Printed Library Materials. Cover design by Patricia F. Cleary. For additional copies, pricing for bulk purchases, andlor information about other Humana titles, contact Humana at the above address or at any of the following numbers: Tel: 973-256-1699; Fax: 973-256-8341; E-mail: [email protected] or visit our website at http://humanapress.com Photocopy Authorization Policy: Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by Humana Press Inc., provided that the base fee of US $20.00 per copy is paid directly to the Copyright Clearance Center at 222 Rosewood Drive, Danvers, MA 01923. Forthose organizations that have been granted a photocopy license from the CCC, a separate system of payment has been arranged and is acceptable to Humana Press Inc. The fee code for users of the Transactional Reporting Service is: [1-58829- 142-1/03 $20.00]. 10987654321 Library of Congress Cataloging in Publication Data Additional material to this book can be downloaded from http://extras.springer.com. Constant, Jules, 1922- Essentials of bedside cardiology: with a complete course in heart sounds and murmurs on CD 1 by Jules Constant.--2nd ed. p. ; cm. -- (Contemporary cardiology) Rev. ed. of: Essentials of bedside cardiology for students and house staff. 1st ed. c1989. Includes bibliographical references and index. ISBN 978-1-4684-9754-0 ISBN 978-1-59259-338-5 (eBook) DOI 10.1007/978-1-59259-338-5 I. Heart--Examination. 2. Heart--Diseases--Diagnosis. 3. Heart--Sounds. 4. Medical history taking. I. Constant, Jules, 1922- Essentials of bedside cardiology for students and house staff. II. Title. III. Contem• porary cardiology (Totowa, N.J. : Unnumbered) [DNLM: I. Heart Diseases--diagnosis. 2. Heart Sounds. 3. Physical Examination. WG 141 C757ea 2002] RC683.C593 2002 616.1'2--dc21 2002190222 To Elizabeth my wife, without whom this book might never have been published Preface

Essentials of Bedside Cardiology, Second Edition, like the first edition, is designed for those who wish to balance technological advances with increased personal skill in history taking and physical examination. It is important to teach physicians that all technologies now in use for diagnosing cardiovascular disorders, such as echocardiography, can have false positive and false negative results. It is not always wise to rely on these technologies alone; indeed, they may not even be available in some settings. Even when the full panoply of up-to-date techniques is at the physician's disposal, the patient may not be a good candidate for an echocardiogram, or the technician or reader may not be well qualified, or the equipment itself may be substandard. Technology must be combined with physical examination to decide what is true and what is false. The practice of expert history taking and physical examination returns the physician to the actual patient, where the physician can feel like a "real doctor" rather than a mere interpreter of laboratory data. Essentials of Bedside Cardiology, Second Edition, strives to teach and not simply to tell the facts, relying on three basic methods derived from the psychology of teaching and learning: 1. Explain the facts. 2. Use a question and answer format-the Socratic method. 3. Provide tricks or mnemonics to help the reader remember the facts. The value of the Socratic method is its ability to focus attention and stimulate thinking. The format of Essentials of Bedside Cardiology, Second Edition, supports this goal by allowing the reader to cover up the answer and so use the book as a programmed learning tool. A demonstration of all the heart sounds and murmurs with detailed explanations of what is being heard is provided on the enclosed CD. No simulators have been used. In addition, the use of phonocardiograms and tracings for teaching is encouraged throughout the text.

vii viii Preface

The index also is a learning tool, having been compiled by me, based on 40 years of teaching experience, with the goal of efficiently guiding the reader to the information needed. The glossary, too, is designed for all levels of readers, constituting a virtual encyclopedia of terms for the cardiologist, student, and noncardiologist alike. Terms that are fully explained in the glossary are typeset in boldface throughout the text as one more pedagogical aid. Essentials of Bedside Cardiology, Second Edition, is the only book that teaches how to recognize normal jugular waves using updated terminology, how to measure jugular pressure accurately, how to record findings with an auscultogram, how to tell cardiac function by the cuff and Val salva method, how to diagnose cardiomegaly on an X -ray without using the outdated cardiothoracic ratio, and how to tell whether the is due to the right or left ventricle. It also gives the latest explanation for the changing loudness of the first heart sound with changing P-R intervals and updates methods for recording and taking an accurate blood pressure.

lules Constant, MD, FACC Contents

Preface ...... vii A Complete Course in Heart Sounds and Murmurs on CD ...... Inside Back Cover

1 THE CHECKLIST IN HISTORY TAKING ...... 1 Advantages of a Checklist 1 Reminder List History 2 Etiologies 3 Follow-Up Questions 7 New York Heart Association Functional and Therapeutic Classification 14

2 CARDIAC CWES FROM PHYSICAL ApPEARANCE ...... •...... •.. 17 Skin 17 Congenital and Acquired Facies 20 Eyes 22 Edema 25 Extremities 26 Chest and Respiration 27

3 ARTERIAL AND PRESSURES ...... 29 Method of Arm Palpation 29 Rates of Rise and Pulse Volume 30 37 Palpation of the Leg Pulses 38 Estimating Systolic Blood Pressure by Palpation Alone 39 Accurate Blood Pressure Measurement 40 41 Chest Piece Placement and Choice 42 Equipment Sources of Error 43 Systolic Pressure Measurement 44 Diastolic Blood Pressure Recording 45 Accuracy of Blood Pressure Recording 46

ix x Contents

Summary of How to Take Ann Blood Pressures by Listening for Korotkoff Sounds 48 49 Pulsus Alternans 49 Blood Pressure and Pulses in the Legs 51 55 Capillary Pulsation 58 Abdominal (AAA) 58 How to Tell Cardiac Function by Blood Pressure Response to a Valsalva Maneuver 58

4 JUGULAR PRESSURE AND PULSATIONS ...... 63 Venous Pressure by Jugular Inspection 63 How to Use the Internal Jugulars as a Manometer 65 Method of Obtaining an Accurate Measurement of Venous Pressure 66 How to Tell Jugular from Carotid Pulsations 68 The Abdominal Compression Test (Hepatojugular Reflux) 70 Jugular Pulse Contours 73

5 INSPECTION AND PALPATION OF THE CHEST ...... 89 Ventricular Enlargement from Examination of the Chest 89 Cardiac Dilatation Signs in the Left Lateral Decubitis Position 94 Right Ventricular Enlargement 96 Left-Sided Causes of Left Parasternal Movement 99 X-ray Evaluation of Cardiac Size 101 Diagnosis of Ventricular Hypertrophy by Physical Examination of the Precordium 103

6 THE ...... 111 The Bell Chest Piece III The Smooth Diaphragm 113 The Tubing 114 Air Leaks and Ear Tips 115 Summary of Good Stethoscope Characteristics 116

7 DIAGRAMMING AND GRADING HEART SOUNDS AND MURMURS ...... 117 The Auscultogram 117 Grading of Heart Sounds and Murmurs 119

8 THE FIRST HEART SOUND (S) ...... 121 Physiology of the First Sound Components 121 The Ml Plus Aortic Ejection Sound as the Cause of a Split Sl 123 The Pulmonary Ejection Sound 125 Loudness of the M, 129 Contents xi

9 THE SECOND HEART SOUND (S) ...... 133 Physiology and Nomenclature for the S2 133 Explanation of Normal Splitting Sequence of S, J34 Physiology of the Normally Moving Split 136 . Loudness of the Components of S2 137 The Widely 143

The A2-P2 in Pulmonary Stenosis 144 ASDs with Narrow Splits 146 Differential Diagnosis of the Fixed Split 147 The Narrowly Split S2 148 The S2 Split in Pulmonary 149 The Reversed or Paradoxically Split S2 150

laTHE OPENING SNAP ...... 155 Mechanism and Timing 155 Relation Between the 2-0S Interval and the Severity of Mitral Stenosis 156 The Loudness of the Opening Snap 159

How to Tell an A2-P2 from an A2-OS 160

11 THE THIRD HEART SOUND (S) ...... 163 Nomenclature 163 Timing 163 Mechanism of Production 165 The Physiological S3 166 Loudness of the S, 167 The Exaggerated Physiological S, 169 The Pathological S, 170 . The Physiological Versus the Pathological S,170 The Right Versus the Left Ventricular Sl 17i The S3 Versus the Opening Snap 172

12 THE (S4) ...... 175 Nomenclature 175 Mode of Production 175 Recognizing the Rhythm of the S4 Gallop 177 The Physiological S4 177 The Pathological S 4 178

Loudness and Audibility of the S4 180 Differentiation of the S4 from the S3 181 Differentiation of an S4-S1 from a Split Sl (M1-A1 or M1-T1) 182 Severity of Cardiac Dysfunction and Presence of an S4 183 The S4-S1 Interval and Severity of Dysfunction 184 Summation and Augmented Gallops 184 The Pacemaker S4-Like Click 186 xii Contents

13 EJECTION MURMURS ...... 187 Physical Causes 187 Characteristics of the Ejection Murmur 188 Types of Ejection Murmurs 193 Systolic Flow Murmurs 193 Ejection Murmurs 200 Pulmonary Stenosis Ejection Murmurs 206 The Effect of Respiration on PS Ejection Murmurs 208 Thoracic, Subclavian, Carotid, and Thyroid Artery Flow Murmurs 209

14 SYSTOLIC REGURGITANT MURMURS ...... 213 The Effect of a Sudden Long on Left-Sided Regurgitant Murmurs 214 Mitral Regurgitation Murmurs 215 Effect of Drugs and Maneuvers on Systolic Regurgitant Murmurs 223 The Prolapsed Mitral Valve Syndrome (Barlow's Syndrome) 225 Tricuspid Regurgitation (TR) Murmurs 229 The Cardiorespiratory Murmur 230 VSD Murmurs 231 234

15 DIASTOLIC MURMURS ...... 243 Diastolic Atrioventricular Valve Murmurs 243 Tricuspid Diastolic Flow Murmurs 253 Tricuspid Stenosis (TS) Diastolic Murmurs 253 Diastolic Semilunar Valve Murmurs 254 Pulmonary Regurgitation Murmurs 258 Pericardial Friction Rubs 259

16 ABDOMINAL MURMURS ...... 265 Normal Abdominal Murmurs 265 Abnormal Abdominal Murmurs 265

Glossary ...... 267 Index ...... 287