Cardiac Physical Diagnosis

• The great majority of diagnosis of Cardiac Physical Diagnosis: can be made at the office or the bedside. A Proctor Harvey Approach • Usually you do not need sophisticated, elegant laboratory equipment. By Keith A. McLean, M.D.

Cardiac Physical Diagnosis Cardiac Physical Diagnosis

• The complete cardiovascular examination • Pulsus alternans: A that alternates consists of the 5 finger method: amplitude with each beat. (i.e. STRONG, •history weak, STRONG, weak) • physical exam • You may miss it if you palpate with very •ECG firm pressure; use light pressure like a • chest x-ray blow of breath on our fingers. • simple laboratory tests. • History is generally the most important.

Cardiac Physical Diagnosis

• The Harvey method is: • 1. Inspection, take time to look closely • 2. Start at the left lower sternal border for an overview. Listen to the first sound, then the second sound, then sounds in systole, murmurs in systole, and sounds in diastole and murmurs in diastole.

1 Cardiac Physical Diagnosis

• S3 gallop is heard better and louder with the patient: • in the left lateral decubitus position • after palpating the PMI, keeping your finger on the location of the PMI and placing the bell of the stethoscope over the PMI • The gallop may alternate in intensity with every other beat and pressure on the scope can eliminate the gallop.

Cardiac Physical Diagnosis

• PEARL: S3 or S4 may be missed in an emphysematous chest with an increase in AP diameter secondary to COPD, if you listen at the usual space, LLSB or apex. • If you listen over the xyphoid or epigastric area, it may easily detected.

Cardiac Physical Diagnosis

• Gallops are diastolic filling sounds S3 and S4. • The best position to hear gallops, as they may only be heard in the left lateral decubitus position, over the PMI with the bell barely making a seal with the chest wall. • Firm pressure diminishes or eliminates S3 or S4.

2 Cardiac Physical Diagnosis Cardiac Physical Diagnosis

• How to differentiate between an S4, a split S1, • A S4 is frequently found in patients with and an ejection sound: coronary disease. • S4 is eliminated with pressure on the • Harvey says: “If an S4 isn’t found in a stethoscope patient with a previous history of MI, one • Pressure does NOT eliminate ejection sounds or might wonder if such a diagnosis was a split S1 correct.” • S4 is usually NOT heard over the aortic area • Aortic ejection sound IS heard over the aortic area

Cardiac Physical Diagnosis S3 Gallop

• S4 is a common finding in patients with • S3 is not a loud sound. Most of them are HTN. faint. • Harvey personal approach; “If the S4 is • Most S3’s are heard every 3rd or 4th beat present and the blood pressure is 140/90 rather than with every beat. On the other or greater, medication is indicated for hand, S4 is more likely to be heard with HTN, because the presence of the S4 almost every beat. already means that the has been • S4 disappears with atrial fibrillation. S3 affected.” persists with atrial fibrillation.

S3 Gallop

• Some instructors have used the words “Tennessee” and “Kentucky”. • Ten-nes-see = S4. Ken-tuck-y = S3. • These are often confusing and are discouraged.

3 Congestive Heart Failure Hydrothorax

• The earliest, most subtle signs and • It accompanies CHF and may be bilateral. More findings of cardiac decompensation are: commonly presents in the right thorax. Why? • Pulsus alternans • Gravity • Patients are more likely to sleep on their right •S3 side. Patients with large and arrhythmias such as a fib are conscious of the heart action while lying on the left, therefore they prefer to sleep on their right side.

Hydrothorax Congestive Heart Failure

• PEARL: When a left hydrothorax is • Cheyne-Stokes respirations, which usually present in a patient with heart disease, indicates very advanced heart failure. It rule out the possibility of an etiology other can also indicate cerebrovascular disease than heart failure. or drug effects, such as narcotics.

Congestive Heart Failure The Inching Technique

• When it is not possible to control atrial • The inching technique is the most fibrillation after trying several accurate and most practical way of timing antiarrhythmic drugs, it may be best for extra and murmurs. both physician and patient to accept and live with a chronic atrial fibrillation with a • The stethoscope is moved or “inched” ventricular rate in the 60’s or 70’s. down over the precordium from the aortic • Diuretics may be more effective on the area to the apex. days when less physical activities and more rest takes place.

4 The Inching Technique

• You can also start at the apex and LLSB and inch upward towards the base of the heart. • First, start over the aortic area, remembering that the second heart sound over the aortic area is almost always louder than the first.

Aortic Regurgitation

• Positions and techniques for : • The murmurs of aortic regurgitation are generally heard when the patient is sitting upright, leaning forward, breath held in deep expiration.

5 Aortic Regurgitation Aortic Regurgitation

• Using firm pressure of the flat diaphragm • A faint aortic diastolic murmur may be of the stethoscope and listening along the overlooked if only the bell of the 3rd left sternal border. stethoscope is used. • There should be firm pressure on the stethoscope, enough to leave an imprint of the diaphragm chest piece on the chest wall, which may be necessary to bring out a faint murmur, grade I or II.

Aortic Regurgitation Aortic Regurgitation

• Other positions for auscultation of the diastolic • However, some diastolic murmurs are best murmur of aortic regurg: • 1. When the patient lying on his or her stomach, heard along the right sternal border rather and propped up on the elbows. Also this position than the left. is useful to detect a . • 2. The patient standing, leaning forward with • The right-sided aortic diastolic murmur is his/her hands on the wall. usually associated with dilatation and • The great majority of murmurs of aortic rightward displacement of the aortic root. regurgitation are heard louder at the left sternal border compared with the counterpart on the right.

Aortic Regurgitation Aortic Regurgitation

• This has been associated with: • The key interspaces are the 3rd and 4th • - right, as compared with their counterparts, • -aortic dissection the 3rd and 4th left interspaces. •-HTN • The 3rd interspaces are more likely to • -arteriosclerosis show the definitive difference. • -rheumatoid spondylitis • -Marfan’s syndrome • An aortic diastolic murmur louder at the • -osteogenesis imperfecta right sternal border than the left • -VSD with aortic regurgitation immediately suggests the diagnosis just • -syphilis described.

6 Aortic Regurgitation Aortic Regurgitation

• Another cardiac PEARL concerning right- • Aneurysm and or dissection of the first sided aortic diastolic murmurs is what we portion of the ascending aorta. term a formula. • Severe pain in the upper back between • Diastolic + aortic diastolic + right-sided = the shoulder blades is a clue to an aortic dissection. • HTN mumur aortic diastolic • If the chest x-ray shows rightward murmur displacement of the aortic root and a murmur of aortic regurgitation is present, it is most likely to be the right-sided type.

Aortic Regurgitation Aortic Regurgitation

• If atrial fibrillation is present, suspect the • Other findings of severe aortic possibility of concomitant mitral valve regurgitation include: lesions. • typical up and down bobbing of the head, (demusset’s sign) • frequent and profuse sweating • unexplained pain or tenderness to touch over the carotid • unexplained mid-abdominal pain • quick rise or collapsing arterial pulse

Aortic Regurgitation Aortic Regurgitation

• Proctor Harvey says you should palpate • The neck pain from aortic regurgitation simultaneously the radial, brachial or can be a transient tenderness and pain carotid pulse with the femoral pulse. If the over the carotid arteries, may be carotid, brachial or radial pulsations are characterized by exacerbations and better felt than the femoral, diagnose remissions that are unaffected by aortic coarctation of the aorta in addition to valve surgery, the etiology of which is severe aortic regurgitation. uncertain, probably produced in the wall of the carotid artery-could be from carotid pulsations against tender lymph nodes.

7 Aortic Regurgitation Aortic Regurgitation

• The patient with aortic regurgitation has a loud • In Proctor Harvey’s experience with the aortic systolic murmur, even with a palpable most severe leaks of the , the systolic thrill. Austin-Flint murmur occurs approximately • With aortic regurgitation, at the apex generally a in the mid portion of systole and often with localized spot over the left ventricle is best heard some components in pre-systole. with the patient in the left lateral decubitus position. Listen with the bell of the stethoscope over the PMI. A diastolic rumble may be present. This is the Austin-Flint rumble.

Aortic Regurgitation Aortic Regurgitation

• The quick rise, or flip, of the radial pulse • The failure to do so is understandable may be even better detected by having the because the diastolic blood pressure may patient raise his arms over his head. This be low-normal or be slightly or moderately simple maneuver may make this type of reduced compared with the very low pulse more evident. diastolic blood pressure present with • The prompt recognition of acute severe severe chronic acute regurgitation. aortic regurgitation as can occur from infective affecting the aortic valve may be life-saving.

Aortic Regurgitation

• Also, with the acute type, the to and fro systolic and diastolic murmurs heard best along the left sternal border may be shorter in duration and fainter. Also, the first heart sound is likely to be faint. • Early closure of the mitral valve is due to a great leak of the aortic valve into the left ventricle, thereby closing the mitral valve prematurely.

8 Aortic Stenosis

• The typical murmur of aortic stenosis is • Aortic stenosis murmur is heard equally harsh, similar to the sound of clearing loud on both sides of the carotid arteries. one’s throat. Aortic events are usually well • Palpation can be of great aid in the clinical heard at the apex. diagnosis of aortic stenosis using both • The murmur of aortic stenosis hands; the right hand is placed over the characteristically radiates up into the apex of the left ventricle and left hand over supraclavicular area of the neck, over the the aortic area. carotids, and the suprasternal notch.

Differentiating Mitral Aortic Stenosis Regurgitation from Aortic • Left ventricular impulse indicating hypertrophy of Stenosis after a Pause the left ventricle can be felt, and a palpable systolic thrill may be detected over the aortic • The systolic murmur of mitral regurgitation area, the direction of which is towards the right remains unchanged after a pause. neck and shoulder. • In contrast the systolic murmur of aortic • The direction of the thrill with aortic stenosis is stenosis is louder after a pause following a towards the right neck or clavicle. premature beat. • The direction of the thrill of pulmonic stenosis is towards the left neck or clavicle.

• There may be wide transmission of aortic systolic murmur over the entire precordium, may be heard over the aortic area, the pulmonic area, the 3rd left sternal border, the left lower sternal border, and the apex. • Aortic events are often clearly heard at the apex. • Aortic stenosis murmurs are usually widely transmitted throughout the neck as well.

9 • The systolic murmur is often louder over the clavicles, illustrating the importance of transmission by bone. • The radial pulse, brachial and carotid may show a slow rise with a slow descent, which is consistent with aortic stenosis. • Proctor Harvey suggests that the diagnosis of aortic stenosis may be made from palpation alone.

Aortic Stenosis Aortic Stenosis

• Concentrate on the murmur after a pause • With mitral regurgitation, the murmur with atrial fibrillation or with a pause after a remains essentially unchanged. premature beat. • PEARL: The Musical Murmur • With aortic stenosis, the murmur increases • If one hears a high-frequency, musical, in intensity after a pause. diamond-shaped systolic murmur heard only at the apex, immediately think of and rule out aortic stenosis.

Aortic Stenosis Aortic Stenosis

• It is clinically apparent that the typical • Another cardiac PEARL is the rhythm. harsh, low frequency murmur of aortic • The rhythm with a single aortic lesion is stenosis can be filtered or altered by regular normal sinus. This applies to emphysematous changes and an increase aortic stenosis, aortic regurgitation, or in diameter to result in this musical when there is both stenosis or murmur. regurgitation.

10 Mitral Regurgitation Mitral Regurgitation

• However, if one thinks that there is only • Careful search may then detect, for single aortic lesion, such as aortic example, an unsuspected mitral stenosis, stenosis, when atrial fibrillation is present, a rumble of which may only be detected always look carefully for concomitant when the patient is turned onto the left mitral valve involvement. lateral position and the physician listens over the PMI with the bell of the stethoscope held lightly and barely touching the skin of the chest wall.

The Rheumatic Heart Syncope in Aortic Stenosis

• Another cardiac PEARL is the rheumatic • The patient having symptoms of syncope, heart. near syncope, or dizziness related to • If only the aortic valve is diseased, it is severe, advanced aortic stenosis should most likely NOT of rheumatic etiology. be promptly referred for surgical valve • Rheumatic heart generally has 2 valves replacement. involved, the aortic and the mitral. • Their next episode of syncope could be • Cardiac PEARL: In men, the aortic valve their last. is most likely to be diseased. In women, it’s the mitral valve.

The Innocent Systolic Murmur in Systolic Murmurs of the Elderly the Elderly • As people live longer, they often develop • -can happen in elderly patients with an aortic systolic murmur that may systolic murmurs over the aortic area as progressively increase in intensity, well as the pulmonic area. produce symptoms of fatigue, dyspnea, near syncope or syncope. • Elderly people ages 60-90 develop an • This is usually caused by a tricuspid aortic aortic systolic murmur due to a mild to valve. moderate degree of sclerosis or stenosis. • This is the most common cause of valve stenosis in patients age 60-90 yrs old.

11 The Innocent Systolic Murmur in The Innocent Systolic Murmur in the Elderly the Elderly • Calcium deposits of varying degree occur • The pathology of valve shows dense on the valve, but may not affect its function sclerotic changes with calcification of and the patient may have no symptoms. portions of the three leaflet aortic valve. • This murmur is termed “innocent systolic • The commissures are not fused at their aortic murmur of the elderly”. junction with the aortic ring. • Usually no treatment is required, nor is heart catheterization necessary.

The Innocent Systolic Murmur in The Innocent Systolic Murmur in the Elderly the Elderly • Although a murmur of grade 3 or less may • An innocent murmur of the elderly (more have been heard in a patient with such a likely in males) may continue a benign valve, no symptoms may be present. course for years; on the other hand, • They may have a faint 1 or 2 aortic progression can gradually occur and diastolic murmur. cause symptoms.

Cardiac PEARL Bicuspid Aortic Valve

• Sometimes, unexplained GI bleeding • From ages 6 to approximately 60, bicuspid occurs in patients with aortic stenosis. aortic valve is the most likely cause of • Following an operation for aortic stenosis, aortic stenosis, and ranks second only to the bleeding was alleviated. Often no mitral valve prolapse as the most common explanation was found. valvular lesion.

12 Bicuspid Aortic Valve Bicuspid Aortic Valve

• For example, if aortic stenosis is • After the age of 60, the most common diagnosed in a man aged 55 and it is a cause of aortic stenosis is not congenital single valvular lesion, the diagnosis in the in origin, but rather a three leaflet great majority of patients will be congenital (tricuspid) aortic valve. bicuspid aortic valve. • Cardiac PEARL: If the aortic valve is involved as a single lesion, the heart • Calcification of the valve will be present in rhythm is regular. If atrial fibrillation is virtually 100% of these patients. present, always suspect and rule out concomitant mitral valve pathology.

Bicuspid Aortic Valve Bicuspid Aortic Valve

• It is of great importance to differentiate the • Frequently, it has a harsh quality similar to murmur of congenital aortic stenosis from the sound of clearing one’s throat. an innocent systolic murmur. • In some, an early blowing, high frequency • Early diagnosis can be readily aortic diastolic murmur of grade 1 to 3 is accomplished in the physician’s office. heard. • Most commonly, a congenital bicuspid valve shows an early to mid-systolic murmur of grade 1-3 intensity is present.

Bicuspid Aortic Valve Bicuspid Aortic Valve

• Firm pressure on the stethoscope’s flat • Since aortic events are usually well heard at the diaphragm chest piece should always be apex, the systolic murmur of aortic stenosis may used to best detect this diastolic murmur, be detected from the aortic area to the apex. listening along the left sternal border, with • This is also true of the aortic ejection sound that the patient sitting upright, leaning forward, is another key to this condition. and breath held in deep expiration. • Congenital bicuspid aortic valve ejection sound is unchanged by respiration and is the same over the pulmonic area, the 3rd LSB, and at the LLSB.

13 Bicuspid Aortic Valve Bicuspid Aortic Valve

• The ejection sound is not eliminated with • It is of interest that, as part of the spectrum firm pressure of the stethoscope, as of findings in congenital bicuspid aortic should be the case with an atrial gallop. valve, aortic regurgitation rather than • Cardiac PEARL: The ejection sound is a stenosis may be the dominant lesion and hallmark of a congenital bicuspid aortic in perhaps 5% of cases it may be of an valve and occurs with “doming” of the advanced, severe degree. valve in early systole.

How to Differentiate Congenital Bicuspid Aortic Stenosis from an Innocent Murmur

• An innocent murmur will have no ejection sound, • Cardiac PEARL: If possible, try to obtain and would be associated with a normal EKG and an EKG while the patient still has the chest chest x-ray. pain. • EKG may show abnormalities such as left axis deviation and some increase in voltage over the • It is also helpful to have the patient have left ventricle, consistent with LVH. an EKG during any arrhythmia or • The chest x-ray may show some post-stenotic palpitation or other symptom of which he dilatation of the ascending aorta or other variant complains. from normal.

Pain of Myocardial Infarction Pain of Myocardial Infarction

• -severe precordial substernal discomfort • The pain may also radiate up into the neck, that radiates up to the left shoulder and more likely the left, but sometimes the right or then down the left arm and along the both sides of the neck. inside of the arm rather than the outside. • Occasionally, the pain seems to be localized in the jaw, making the patient think that this is a • At times, both the right and left arms are pain in a tooth. involved with the radiation of the pain, and • Descriptions of the classic chest pain may feel in rare patients the pain is more noticeable “like an elephant stepping on my chest” or a in the right arm than the left. lasso around the chest pulling tighter and tighter.

14 Pain of Myocardial Infarction Pain of Myocardial Infarction

• Sweating frequently accompanies the • To elicit a description of the typical pain more severe pain of an acute myocardial caused by myocardial ischemia, ask the infarction. question, “What happens if you walk • Nausea and vomiting may also be present. briskly up a hill, against the wind, in cold • The patient cannot seem to find a position weather?” where there is relief from the pain.

Pain of Myocardial Infarction Pain of Myocardial Infarction

• Levine’s sign, is when the patient while • As a variant of this sign, the patient may describing his symptoms of coronary press over this area with the extended ischemic chest pain, may make a fist with fingers of both hands; less commonly, the his hand and press it over his substernal patient points and presses with one finger area. This is the Levine’s Sign, described (usually the index finger) over the by the late Samuel A. Levine of Boston. substernal area in describing the discomfort.

Pain Between the Shoulders Pain Between the Shoulders

• Chest pain more localized in the shoulders or • Occasionally, a patient will describe the between the shoulder blades in the back should alert one to the possibility of aortic dissection. radiation of the ischemic pain from • Although, the pain of acute myocardial infarction coronary artery disease as being “like an can indeed radiate to this area in the back, the advancing tidal wave”, from the substernal localization of the pain in the shoulder region area to the left shoulder and then down and the back also is very consistent with the the left arm to the fingertips. When the pain caused by rupture of the aorta. pain begins to subside, the “tidal wave” • Be especially suspicious if the EKG does not indicate myocardial infarction. reverses direction back to the heart.

15 Non-Coronary Chest Pain Non-Coronary Chest Pain

• It is worthwhile to explain to patients the • -Coronary pain is not accentuated by type of chest pain that generally is NOT external pressure over the precordium. related to heart disease: • -Pain over the apical region of the heart or • -A constant “aching” pain that might be in over the right anterior chest region is not the substernal area and lasts all day is typical of coronary artery pain. usually not caused by heart disease. • -The fleeting, momentary pain in the chest • Nor is pain that is present only in one described as a needle jab or stick, lasting position and not in others. only a second or two, is not heart pain.

Ear Lobes

• At times you may see movement of the patient’s ear lobes coincident with systole. • This should immediately suggest two possible causes: -severe aortic regurgitation, or, severe tricuspid regurgitation • In each instance, the movement of the ears reflects the transmitted impulse from the carotid artery (aortic regurgitation) or the jugular (tricuspid regurgitation).

Carcinoid Tumor Infective Endocarditis

• When flushing occurs or the patient has • Antibiotic prophylaxis as outlined by the AHA is indicated not only for extractions of teeth but persistent violaceous or erythematous also for the simple procedures of cleaning facial flushing, then the carcinoid tumor of and/or filling. the intestine has metastasized to the liver. • Infective endocarditis has been definitely • The serotonin in the bloodstream of documented to occur with these simpler procedures. patients with the carcinoid syndrome can • Antibiotic prophylaxis should also be given to cause scarring of the pulmonic valve, patients with valvular heart disease. Infective producing the pulmonic systolic murmur. endocarditis can also affect valves replaced at surgery.

16 Mitral Valve Prolapse Mitral Valve Prolapse

• It should be policy to give antibiotic • Harvey disagrees with this, as he can cite prophylaxis to ALL patients with mitral many patients with MVP who have valve prolapse-those having a click or transient murmurs as well as clicks. clicks, as well as those patients with a • He has personally observed patients with systolic murmur. proven infective endocarditis who had only • Some authorities recommend prophylaxis a single click or clicks and never had a only for patients with mitral valve prolapse systolic murmur detected on careful who have a systolic murmur. auscultation.

• At times, proper and efficient auscultation over • Sometimes a particularly garrulous patient the chest and neck is accomplished by having continues to talk while we try to listen; the patient stop breathing. several things are helpful: • In this way breath sounds are not interfering. • politely ask to please stop talking • When we ask the patient to do so, we too, should also stop breathing. This reminds us • say “let me see your tongue” when to tell the patient to resume breathing; if • say “hold your breath we don’t remember, we may find our patient struggling to keep from taking a breath.

The Five Year Rule Innocent Systolic Murmurs

• A new drug, procedure, technique or piece • The innocent systolic murmur is short, of equipment should ideally stand the test occurring in early to mid systole. It is not of time – about five years – before it is fully holosystolic. Normal splitting of the utilized. second heart sound is present also. • If at the end of this “watching” period • The innocent systolic murmur is very nothing negative has evolved, then it may common. It is a frequent finding in be utilized as indicated. children and teenagers, and less likely in adults.

17 Innocent Systolic Murmurs Innocent Systolic Murmurs

• Out of 100 school children aged 11 or 12, • The innocent systolic murmur is early to mid Harvey found approximately 60% who had an systolic; it is generally grade 1 to 3 on a basis of innocent systolic murmur. six (Samuel A. Levine’s classification) • It is also of interest that in this particular group, • Splitting of the second heart sound is normal, he found 100% had a normal physiologic third becoming wider with inspiration and single or heart sound; 100% had a normal physiologic closely split with expiration. venous hum that was detected listening over the • The EKG and cardiac silhouette of the heart are right supraclavicular fossa, with the head turned normal. “on a stretch” to the opposite direction. • The history is negative, except for the finding of a murmur.

Murmurs of pathologic conditions can be Murmurs of pathologic conditions can be similar to innocent murmurs, but they have similar to innocent murmurs, but they have other associated findings. other associated findings. • For example, has a • The x-ray shows increased blood flow in wide, so-called “fixed” splitting of the the lungs and enlarged pulmonary second heart sound. arteries. • The EKG has changes, particularly in lead • The murmur of a congenital bicuspid aortic valve can in itself be similar to the V1: right ventricular conduction delay innocent murmur, but an ejection sound is (RSR1), RBBB or RVH. present with the aortic stenosis which is well heard over the precordium from the aortic area to the apex.

Location Innocent systolic murmurs

• A common misconception is that an • are commonly found in children and in the innocent murmur is localized over one early teen years. They are less common area, such as the pulmonic area, third left in adults. sternal border, or aortic area. • An interesting exception is the fact that • Instead, innocent murmurs are frequently innocent systolic murmurs were found in heard in other areas of the precordium, more than 90% of 90 NFL players although they may be loudest over one personally examined. particular area.

18 Innocent systolic murmurs Innocent systolic murmurs

• Innocent systolic murmurs occur in early to • More sophisticated laboratory studies such mid-systole. as echocardiography and cardiac • They are generally Grade 1-3 in intensity catheterization are usually not necessary and in the great majority are readily for diagnosis and only add to the expense diagnosed in the office or at the bedside. incurred by the patient or family. • The second heart sound is of normal intensity, normally split and the degree of splitting increases in normal fashion with inspiration.

Differentiation from other Differentiation from other conditions conditions • A murmur due to a bicuspid aortic valve has an • Innocent systolic murmurs are often aortic ejection sound that is unaffected by similar to murmurs caused by a bicuspid respiration. aortic valve, mild pulmonic stenosis, or • A murmur due to congenital valvular pulmonic atrial septal defect. How to tell the stenosis also has an ejection sound but it will vary, becoming fainter or even disappearing on difference? inspiration, although heard louder on expiration. • Consider the concomitant findings. • The murmur of pulmonic stenosis also is more likely to have a wider split of the second heart sound that does not become single on expiration. • RVH may be noted on the EKG.

Differentiation from other conditions Differentiation from other conditions

• With a murmur due to ASD, there is wide • Innocent murmurs are better heard in young “fixed” splitting of the second heart people who have thin chests than in those who sound. are obese or muscular. • Once the diagnosis of innocent murmur is • This finding, together with the EKG and established, it is not wise or necessary to have x-ray changes of ASD, can quickly make the patient return at intervals of several months the distinction between this serious or a year to keep check on this murmur. murmur and an innocent murmur. Otherwise, it can be logically interpreted: “The doctor is not sure; if not, why do I have to return?”

19 Innocent Murmurs Systolic Murmur in the Elderly

•4 s • Systolic murmurs in the elderly population are • Soft an expected and usually innocent finding. • They are usually grade 1 to 3 in intensity and • Short best heard over the aortic area or left sternal • Systolic border; it may also be heard over the clavicles • Split (normal ) (bone transmission); in the suprasternal notch, supraclavicular areas of the neck, including over the carotid arteries.

Systolic Murmur in the Elderly Cardiac Pearl

• The murmur frequently has a somewhat • The person who carefully sketches what is musical quality and can be transmitted heard on auscultation becomes down to the apex. Sometimes it can even progressively more expert in the art of be better heard at the apex. auscultation. • Occasionally a faint aortic diastolic • Never has an exception been seen. murmur (grade 1 or 2) is heard in addition to the systolic murmur.

Grading Systolic Murmurs Grading Systolic Murmurs

• Grading of systolic murmurs is important • Grade 1: the faintest murmur that one and very helpful. They are graded from 1 hears with the stethoscope, but often is to 6 based on a system introduced by the not detected immediately. late Samuel A. Levine: • Grade 2: is also a faint murmur, but one will hear it immediately on placing the stethoscope over the chest. • Grade 3: is still on the faint side, but is louder than the Grade 2 murmur.

20 Grading Systolic Murmurs Grading Systolic Murmurs

• On the opposite end of the grading scale, • Grade 5 is also a loud murmur, but it is not Grade 6 is the loudest murmur and can heard unless the stethoscope is actually even be heard without the stethoscope touching the chest wall. actually touching the chest wall. • Grade 4 is a loud murmur and is a • However, as long as one can see daylight significant jump in intensity from Grade 3. between the stethoscope and the chest • Grade 4 murmurs and above can be wall and still hear a murmur, it is a Grade accompanied by a palpable systolic thrill 6 murmur.

Intensity of Murmur Cardiac Pearl

• If a palpable systolic thrill is felt, the • Always rule out aortic stenosis in a patient murmur is at least a Grade 4 intensity. with the following findings: • A very high pitched musical systolic murmur that peaks in mid-systole and can be heard over the precordium (although it may be detected only at the apex) • heart sounds that may be distant or absent.

Cardiac Pearl Cardiac Pearl

• If one hears a holosystolic (or pansystolic) • Therefore, in MR and VSD, there is earlier murmur that occupies all of systole, think emptying of the blood from the left of three conditions: MR, TR, and VSD. ventricle with systole, resulting in earlier • The innocent murmur is not holosystolic. closure of the aortic component of the second sound, thereby producing a wider split.

21 Cardiac Pearl Diastolic Murmurs

• An early to mid-systolic murmur, with • Aortic diastolic murmurs can be loud and normal splitting of the second heart sound, can be caused by varying etiologies. plus an intermittent third heart sound is a • They can be associated with a palpable perfectly normal finding if there are no thrill along the third left sternal border. symptoms or signs of heart disease. Sometimes the murmur has a “to and fro” quality, loud with a very low, somewhat musical quality. • Sometimes the diastolic murmur resembles sawing wood, with the loud component being in diastole.

Pregnancy Mitral Valve Prolapse • A faint grade 1 or 2 early, blowing diastolic murmur of aortic regurgitation might not be • Mitral valve prolapse is synonymous with detected in a pregnant woman, particularly in other terms such as: her last trimester. – Systolic click-murmur syndrome • Remember, also, that almost all pregnant – Billowing mitral valve leaflet syndrome women have an innocent grade 2 or 3 early to – Floppy valve syndrome mid systolic murmur, which may not be heard – Barlow’s syndrome before or after her pregnancy. • The basic pathophysiology is so-called • Most pregnant women have innocent venous myxomatous degeneration of the mitral hums in the neck and innocent systolic murmurs. valve.

Mitral Valve Prolapse Detecting Mitral Valve Prolapse

• The mitral valve is made up of two basic • Mitral valve prolapse often is first components: a fibrosa element and a diagnosed by echocardiogram. spongiosa element. • Your stethoscope, however, is still the best • In this condition, the spongiosa element instrument to detect and diagnose proliferates. Excessive leaflet tissue can cause a scalloping or hooding effect of the prolapse of the mitral valve. valve. • There may be thinning and elongation of the chordae tendinae.

22 Detecting Mitral Valve Prolapse Detecting Mitral Valve Prolapse

• Both the echocardiogram and angiogram • Supine can fail to document prolapse. • Turned to the left lateral position • It also can be missed by the stethoscope; • Sitting however, generally that is because the • Standing physician is not “mentally set” to listen • Squatting specifically for the typical auscultatory findings, or has not listen carefully in a • Valsalva Maneuver quiet room with the patient in the following • As a rule, findings of mitral valve prolapse on positions: auscultation are best detected using the flat diaphragm chest piece of the stethoscope.

Detecting Mitral Valve Prolapse Detecting Mitral Valve Prolapse

• The findings may be transient, intermittent, • The great majority of patients with mitral varying at times, with some heartbeats valve prolapse are completely having: asymptomatic and need no treatment. • No click or murmur • Some patients have and a • Only a click or clicks degree of chest discomfort. • Only a murmur • Combinations of click and murmur • A musical murmur termed “whoop” or “honk”

Complications and Associated Detecting Mitral Valve Prolapse Findings of Mitral Valve Prolapse • Occasionally sedatives, beta-blockers and • Progressive, increasingly severe MR antiarrhythmics are needed and may be • Ruptured chordae tendinae effective in treatment, although some • Rupture of valve leaflet patients hare not helped by these drugs. • Calcification of mitral annulus • The most serious complication is rupture of a chorda tendinea, which may occur • Transient ischemic attacks spontaneously or as a result of infective endocarditis on the valve.

23 Complications and Associated Seldom Recognized Variant of Findings of Mitral Valve Prolapse Mitral Valve Prolapse • Arrhythmias • Systolic clicks generally occur in mid to • Chest pain late systole. However, a seldom • In some patients, symptoms compatible recognized variant of mitral valve prolapse with neurocirculatory asthenia is that they can occur in early to mid (DaCosta’s syndrome, effort syndrome) systole. •Anxiety • They can be multiple and rapid and can simulate the flipping of a deck of cards or • Cardiac neurosis the creaking of new leather. • Sudden death (rare)

Seldom Recognized Variant of Differentiating Mitral Valve Prolapse Mitral Valve Prolapse from Innocent Systolic Murmur • It can simulate and be misdiagnosed as a • This differentiation generally is not difficult. pericardial friction rub because of these • The typical murmur of mitral valve multiple rapid sounds in systole. prolapse is in mid to late systole, whereas • A pericardial friction rub has 2 or 3 the innocent murmur is in the early to mid components rather than only one in systole: portions of systole. A click (or clicks) frequently accompanies the murmur of • the atrial systolic mitral valve prolapse but is absent with an • the ventricular systolic innocent murmur. • the ventricular diastolic

Differentiating Mitral Valve Prolapse Differentiating Mitral Valve Prolapse from Innocent Systolic Murmur from Innocent Systolic Murmur • A maneuver that increases volume to the • On prompt standing and with a decrease in left side of the heart, such as squatting, volume they may move in the opposite direction may delay these auscultatory findings, and in systole—closer to the first heart sound. therefore the click or murmur may move • Also contributing is the bending of the knees and closer to the second heart sound. hips, which can increase peripheral arterial systolic pressure, and cause movement closer to the second sound, and closer to the first sound on standing.

24 Ejection Sound Terminology

• It is suggested that the term “systolic click” be reserved for and identified with mitral valve prolapse.

Mitral Valve Prolapse-Chest Hypertrophic Cardiomyopathy Abnormalities • When we find on examination of our • Now let’s shake hands again with another patients that there is a chest anomaly such patient, and then place our palpating as straight back, pectus excavatum, fingers over the radial pulse. pectus coronatum, or chest asymmetry, • We note a quick rise of the pulse; this is we have a clue that mitral valve prolapse called a “flip”. might be present. • The quick-rise pulse (also termed Corrigan’s or watterhammer pulse) is • Perhaps 50% of patients with such consistent with aortic regurgitation, a anomalies may have mitral valve prolapse. diagnostic possibility to be ruled in or out.

Hypertrophic Cardiomyopathy Hypertrophic Cardiomyopathy

• Now, searching for the aortic diastolic • We expect to hear the early blowing murmur, we listen with the patient sitting diastolic murmur of aortic regurgitation; upright, leaning forward, and breath held however, we don’t hear it. in deep expiration. • Instead, there is a systolic murmur. Even • We listen with the flat diaphragm of the at this point, we should think of stethoscope pressed firmly against the hypertrophic cardiomyopathy. chest wall at the third left sternal border.

25 Hypertrophic Cardiomyopathy Hypertrophic Cardiomyopathy

• The next step is to use the squatting • We term this the “one, two, three, four diagnosis” maneuver. of hypertrophic cardiomyopathy. • Number one: we find the quick rise pulse • On squatting, the murmur decreases in • Number two: we look for aortic regurgitation intensity (on rare occasions it may even • Number three: we don’t find it; instead a systolic disappear). murmur is present • The murmur becomes louder again on • Number four: with the squatting maneuver, the standing, and the diagnosis of murmur becomes fainter, and on standing again, the murmur gets louder (often louder that it was hypertrophic cardiomyopathy is made. originally). • This is a superb diagnostic maneuver.

Hypertrophic Cardiomyopathy Hypertrophic Cardiomyopathy

• Simple and more effective way: • The Valsalva maneuver, too, can be • The patient stands facing the physician, helpful in diagnosing hypertrophic steadying himself or herself with the left hand on cardiomyopathy. the examining table. • While listening along the left sternal border • The physician listens with the stethoscope over or apex, have the patient take a deep the patient’s left sternal border or apex, thereby obtaining a baseline of the auscultatory findings; breath, blow the breath out and then strain the patient is then told to squat, and then return as if having a bowel movement. to the standing position. • The murmur may increase in intensity, • This is repeated several times. indicating a positive response.

Hypertrophic Cardiomyopathy

• However, some patients, such as the elderly, may have difficulty in performing this maneuver. • A simple and efficient way is to have the patient place his index finger in his mouth, seal it with his lips, exhale and at the point of deep expiration, “blow hard” on the finger.

26 Aortic Stenosis v/s Hypertrophic Hypertrophic Cardiomyopathy Cardiomyopathy • Precordial Impulse: With the patient • Although both valvular aortic stenosis and turned to the left lateral position and hypertrophic cardiomyopathy can, with more palpating over the point of maximum severe degrees of obstruction, produce paradoxical splitting of the second heart sound, impulse of the left ventricle, three impulses it is much more common in patients with may be felt: hypertrophic cardiomyopathy. – The presystolic movement and a double • At times, differentiating the systolic murmur of systolic impulse. This is called the “triple hypertrophic cardiomyopathy from that due to ripple” impulse associated with hypertrophic rupture of chordae tendinae can be quite difficult cardiomyopathy. indeed.

EKG Signs of Hypertrophic Cardiac Pearl Cardiomyopathy

• The differentiation of these two similar • In the absence of any history, symptoms, or murmurs: signs of coronary artery disease, the presence of – If paradoxical splitting of the second heart significant Q-waves and ST and T wave sound in present (in the absence of left changes should alert one to the possibility of bundle branch block on the EKG) the hypertrophic cardiomyopathy-particularly in a diagnosis should immediately be made of teenager or young adult. hypertrophic cardiomyopathy. • A normal EKG practically rules out the diagnosis of hypertrophic cardiomyopathy. Dilated cardiomyopathy, too, often has some abnormality of the EKG.

Mitral Regurgitation Mitral Regurgitation

• Holosystolic: A holosystolic (pansystolic) • If the holosystolic murmur radiates band- murmur suggests three conditions: mitral like (like a belt) from the LLSB to the apex, regurgitation, tricuspid regurgitation, and anterior mid and posterior axillary lines ventricular septal defect. and even to the posterior lung base, this is • If a murmur is holosystolic, this finding diagnostic of mitral regurgitation. alone immediately takes it out of the ballpark of innocent murmurs, which are early to mid-systolic.

27 Radiation of the Systolic Murmur Mitral Regurgitation as a Single of Mitral Regurgitation Valvular Lesion • With significant posterior leaflet damage, • If a patient has mitral regurgitation alone, the radiation is anterior, upward over the and no other significant findings, you can precordium to the base; be almost certain it is not of rheumatic • If anterior leaflet damage predominates, etiology as formerly thought, but related to then the radiation is apt to be posterior, a complication of mitral valve prolapse, from the apex to the axillary lines and such as floppy valve or rupture of a chorda posterior lung base. tendinea.

Acute Mitral Regurgitation Mitral Regurgitation

• The murmur of severe acute mitral • Mitral regurgitation is also a cause of wide regurgitation is loud (grade 4 or above), splitting of the second sound. occupies all of systole, peaks in mid- • With systole, blood is ejected through the usual systole and decreases in the letter part of aortic outflow track and simultaneously through systole. the incompetent mitral valve into the left atrium. • Although women have a higher incidence • The left ventricular contents thereby empty of mitral valve prolapse, men are more earlier than usual, and the aortic valve closure likely to have rupture of chordae (A2) is earlier, which results in a wider split in tendineae, producing mitral regurgitation. both expiration and inspiration.

Mitral Regurgitation Mitral Regurgitation

• All valvular lesions can, at times, be • A third heart sound (S3) is an expected finding in “silent” with no murmur. the more advanced, more severe leaks of the mitral valve. • The most common silent lesion is mitral • A short diastolic rumble may also be heard in stenosis—but the majority of these, failure such patients. to detect a murmur is because the bell of • These auscultatory findings are caused by the the stethoscope is not over the PMI, a large volume of blood in the enlarged left atrium localized spot (which may be the size of a filing the ventricle and producing, in the rapid quarter) where the diagnostic rumble is filling phase, the third sound plus low-frequency heard. vibrations. This rumble is usually not the result of stenosis of the mitral valve.

28 Mitral Stenosis Loud First Heart Sound

• If a diastolic rumble of mitral stenosis is • If a patient who has a normal heart rate has a present it is almost always heard over the loud first sound, always think of two conditions: PMI of the LV with the patient turned to the mitral stenosis and a short P-R interval on the left lateral position. EKG. • Sometimes one has difficulty in palpating • The length of a P-R interval can affect the first this impulse. heart sound. The increase in intensity of the • Almost always, an opening snap of mitral sound is most likely due to the position of the A- stenosis is heard, even with the most V valves at the time systole occurs. extensive degree of stenosis. • If the valves are deeper in the ventricles and systole occurs promptly after the atrial systole, the valves close, making a louder sound.

Loud First Heart Sound

• If the P-R interval is prolonged and the A- V valves have had time to move upward in the ventricles, systolic contraction produces a faint first sound. • A loud first heart sound due to a short P-R interval can simulate the sound of mitral stenosis. • The presence of a normal physiologic third heart sound can be misinterpreted as an opening snap.

Graham Steell Murmur

• It has been said that one cannot tell the • The Graham Steell murmur is not heard difference between the diastolic murmur of over the aortic area and often is localized pulmonary regurgitation (Graham Steell) to the LLSB and generally not heard at the associated with mitral stenosis and that of apex. aortic regurgitation associated with mitral stenosis. • The peripheral pulse has a quick rise “flip” • The murmur of aortic regurgitation may be with aortic regurgitation and not with the heard over the aortic area and transmitted Graham Steell murmur. along the LLSB to the apex.

29 Hemoptysis

• Hemoptysis can occur in the patient having advanced tight mitral stenosis. • Fortunately, the bleeding, which is due to a rupture of a bronchial vein, is generally self limited and does not represent an emergency situation.

Differential Diagnosis of the opening Hemoptysis snap of mitral stenosis and 3rd heart sounds • However, there have been isolated case • Exert pressure on the stethoscope, reports where the bleeding did not which should eliminate the normal third spontaneously subside and surgery was heart sound or the S3 (ventricular) necessary to control it. diastolic gallop; pressure on the • Pulmonary emboli can also cause stethoscope is not likely to eliminate the hemoptysis with mitral stenosis as well as opening snap. with other conditions. This can represent • The opening snap is heard over the a serious complication requiring prompt pulmonic area (sometimes aortic area) recognition and treatment. but not the third sound.

Differential Diagnosis of the opening snap of mitral stenosis and 3rd heart CARDIAC PEARL sounds • The opening snap of a “tight mitral • : In a woman of approximately 30 years of stenosis” is closer to the second sound age, who never had any previous heart than the third sound. problem and then had a sudden onset of • The opening snap serves as a clue to an arrhythmia, the diagnosis that should listen over the PMI of the LV for the “tell head the differential is mitral valve tale” diastolic rumble-not so with the third prolapse. sound, which does not initiate the diastolic rumble.

30 Atrial Flutter Atrial Flutter

• Poorly recognized is that atrial flutter can have a • When the P wave is farther from the R change in intensity of the first heart sound. wave, the first heart sound is faint. • Similar to the fact that a short P-R interval • This is what causes the changes in produces a loud first sound and a prolonged P-R interval produces a faint heart sound, so too, intensity of the first heart sound in with complete heart block, when the complete heart block. independent atrial and ventricular contractions result in a P-wave occurring just before the R wave, the first heart sound in loud.

Atrial Fibrillation Heart Block

• The unexplained onset of atrial fibrillation • When the P-R interval on the EKG is in a patient who is 50 years or older may short, the first heart sound may be loud. be a clue to the presence of underlying • On the other hand, in the same patient, coronary artery disease. when the P-R interval is prolonged (such • However, this is not necessarily true, since as in first-degree heart block) the first other conditions can cause this. heart sound may be faint. • The intensity of the first heart sound will relate to the length of the P-R interval.

Heart Block Heart Block

• A slow ventricular heart rate plus a • This results in a changing intensity of the changing intensity of the first heart sound first heart sound; at intervals, when the P- indicates complete heart block. R interval is short, an abrupt loud first • When the P is close to the first heart sound (the “ de canon” or “cannon sound, it may be loud. shot”) occurs which is an auscultatory • On the other hand, when it is not close finding diagnostic of complete heart block. and the P-R interval is prolonged and at a distance away from the first heart sound, the sound may be faint.

31 Heart Block Heart Block

• Cannon Wave of the Jugular Venous Pulse • A short P-R interval (0.14-0.16 sec) equals • The diagnosis of complete heart block can be a loud first sound. suspected by paying attention to the jugular • P-R interval of 0.17-0.18 sec equals venous pulsations in the neck and by observing a slow regular heart rate approximately 40 bpm). average intensity. • If a sudden “cannon wave” occurs, it indicates • P-R interval of 0.20-0.24 equals faint. that atrial contraction is occurring simultaneously with ventricular contraction. • This is common with complete heart block.

Impulses of Hypertrophy Impulses of Hypertrophy

• An impulse felt laterally over the apical • In such circumstances, the EKG may area is due to left ventricular enlargement show another diagnostic clue: and/or hypertrophy. – Persistent elevation of the S-T segments in the left precordial leads. • A left ventricular aneurysm resulting from • The combination of this impulse plus the a previous myocardial infarction may persistent electrocardiographic findings (in produce a paradoxical systolic bulge with the absence of acute infarction where the systole as the other areas of the left same findings may be present) indicates ventricle are contracting inward. left ventricular aneurysm, most likely due to an old myocardial infarction.

Palpation Palpation

• It is important to palpate over the base of • A palpating hand can feel: the heart. – A loud aortic valve closure of A2 • A palpating hand can feel: – An aortic systolic ejection sound – A loud pulmonic valve closure of P2 – A systolic thrill of aortic stenosis – A systolic ejection sound – A diastolic thrill of aortic regurgitation – A systolic thrill of pulmonic valve stenosis – A right ventricular lift with the bottom (heel) of the palm

32 The Significance of a The Significance of a Paradoxical Pulse Paradoxical Pulse • The term “paradoxical pulse” is really a • Paradoxical pulse also is an important sign misnomer because when it is clinically of pericardial tamponade, and may be a apparent, it is really only an exaggeration sign of restrictive cardiomyopathy, or of the normal pulse. chronic pulmonary disease such as • The decrease in amplitude of the pulse emphysema or asthma. coincident with inspiration may be of help in diagnosing constrictive pericarditis.

Significance of a bisferiens pulse Jugular Venous Pulse

• The double systolic impulse in the radial, • The best way to detect the specific waves brachial, carotid or femoral arterial pulse is of the jugular venous pulse in the neck is called a bisferiens pulse. to be able to SEE both the venous • When this is present, think of three pulsation and the carotid arterial pulsation possibilities: in the same localized area. – A combination of aortic stenosis plus aortic • If we detect a pulsation of the jugular vein regurgitation just before that of the carotid artery, then – more severe aortic regurgitation this has to be an A-wave. – hypertrophic cardiomyopathy.

Jugular Venous Pulse Jugular Venous Pulse

• There are only a few conditions that cause a • There are only a few conditions that “giant” A-wave in the jugular venous pulse: cause a “giant” A-wave in the jugular – 1. Obstruction between the right atrium and the right ventricle occurring with tricuspid venous pulse: stenosis or atresia, or right atrial myxoma, can – (“Eisenmenger cause a prominent A-wave with atrial systole. syndrome”)- pulmonary hypertension, with – Increased pressure in the right ventricle, as atrial defect, ventricular defect, and patent may occur from severe obstruction of the ductus arteriosus) can cause pressure to be pulmonary outflow tract with pulmonic reflected back to the right ventricle, which stenosis, will result in a significant A-wave on produces an A-wave with atrial systole. atrial contraction.

33 Jugular Venous Pulse The First Heart Sound

• There are only a few conditions that • If there is a short P-R interval, the first heart cause a “giant” A-wave in the jugular sound is accentuated (e.g., 0.14 or 0.15 venous pulse: seconds). • If the P-R interval is prolonged, the first sound is – Primary pulmonary hypertension (unknown faint (e.g., 0.19-0.22 seconds or longer). etiology) • When one hears a loud first heart sound in a – Recurrent pulmonary emboli can produce a patient whose heart rate is normal, think of two prominent A-wave of the jugular venous possibilities: A short P-R interval on the EKG pulse. and mitral stenosis.

The First Heart Sound The First Heart Sound

• Splitting of the first sound is due to closure of the • The mitral component is generally louder mitral valve followed by tricuspid valve closure. than the tricuspid component of the first The second sound split is due to aortic valve heart sound, so when the tricuspid closure followed by tricuspid valve closure. component is louder, two conditions • Normally, left sided events of the heart occur should immediately come to mind: before the right; therefore the mitral valve closure component occurs before the tricuspid Ebstein’s anomaly and atrial septal defect. valve closure component of the first heart sound and the aortic valve closure before the pulmonic valve closure of the second heart sound.

The First Heart Sound The First Heart Sound

• Wide Splitting: • Press firmly with the diaphragm of your – Wide splitting of the first heart sound can stethoscope against the skin of the chest occur with complete , wall at the lower left sternal border and /or complete right bundle branch block, Ebstein’s apex. anomaly, and at times with premature ventricular beats. • The S4 will disappear. The two components of the split first sound are not – Splitting of the first sound can be confused with an atrial sound (S4) plus a first sound, or eliminated with pressure; they sound alike a first sound plus an ejection sound. How to and at the aortic area only one component tell the difference? of the split S1 is heard.

34 Atrial Septal Defect Atrial Septal Defect

• A real cardiac pearl and an auscultatory • In the presence of atrial septal defect, the finding that has withstood the test of time is the wide splitting of the second heart sound second heart sound can simulate that of present with atrial septal defect. complete right bundle branch block • In fact, when one hears wider splitting of the • however, one major difference is that second heart sound over the pulmonic area or patients with right bundle branch block third left sternal border, and this does not become single or very closely split with often have no murmur over the pulmonic expiration, then the possibility of atrial septal area as do patients with atrial septal defect must be considered, particularly if a defect. pulmonic systolic murmur is also present.

Atrial Septal Defect Atrial Septal Defect

• It is rare that a grade 2 or grade 3 systolic • When the patient sits up or stands, the murmur is not heard in early or mid wide, fixed splitting remains. portions of systole in patients with atrial septal defect. • This wide splitting is due to the increased volume of blood shunted to the right side • In addition, with complete right bundle branch block, the second heart sound of the heart with the more common generally has more movement that the so- (ostium secundum) type of atrial septal called “fixed” splitting of atrial septal defect. It also may occur with ostium defect. primum defect.

Atrial Septal Defect Atrial Septal Defect

• Often the only clue to an ostium primum • Of course, occasionally an innocent pulmonic defect is left axis deviation on the EKG. systolic murmur can be present in a patient • Also, with the larger shunts at the atrial having right bundle branch block. level, a “flow” rumbling murmur may be • However, the total cardiovascular evaluation can heard along the lower left sternal border; make the correct diagnosis. this is the result of the increased flow of • For instance, the chest x-ray will show the atrial blood shunted from the left atrium to the defect with an enlarged pulmonary artery right side of the heart, producing a more segment, plus increased vascular markings. turbulent flow across the tricuspid valve.

35 Atrial Septal Defect Atrial Septal Defect

• A simple maneuver is to have the patient sit or • A patient with atrial septal defect would have stand up; if the second sound then becomes single, or very closely split on expiration, this is wide, fixed splitting of the second heart sound most likely a normal variant, and not the wide and a systolic murmur of grade 2 or 3. splitting of atrial septal defect. • There would be EKG changes, particularly noted • However, “never say never…” Occasionally, a in V1, such as right ventricular conduction delay, small atrial septal defect can have a single or closely split S2 with expiration. indicated by an RSR1. • Also, remember that the absence of a systolic • Or the patient would have incomplete right murmur (even faint) heard over the pulmonic bundle branch block, complete right bundle area or left sternal border practically eliminates branch block, or right ventricular hypertrophy. the diagnosis of atrial septal defect.

Atrial Septal Defect Atrial Septal Defect

• The x-ray would show an enlarged • Wide splitting of the second heart sound also pulmonary artery segment with increased can be found in patients with anomalous venous vascular markings, and the return. echocardiogram might show findings • This defect is often associated with atrial septal consistent with atrial septal defect. defect but, uncommonly, it does occur alone; in such cases the second heart sound is more • The echocardiogram and cardiac likely to have more movement of the split with catheterization could, of course, document respiration than that of the typically “fixed this. splitting” of atrial septal defect.

Second Heart Sound

• Just as the delay of the pulmonic component with inspiration results in wider splitting, earlier closure of the aortic component can produce wider splitting of the second heart sound. • An example of this is mitral regurgitation of more advanced degrees in which the more significant leaks of the incompetent mitral valve result in earlier emptying of the contents of the left ventricle, thereby producing an early closure of the aortic valve.

36 Second Heart Sound Second Heart Sound

• Wider splitting can also occur in patients with • Complete left bundle branch block is associated large ventricular septal defects; the mechanism with delayed electrical conduction to the left side is similar to that of mitral regurgitation. of the heart, which thereby delays left ventricular contraction. • With paradoxical splitting of the second heart • While aortic valve closure normally precedes sound, the reverse of normal splitting takes pulmonic valve closure, in patients with left place. Instead of the degree of splitting bundle branch block the order may be reversed. increasing with inspiration, the splitting is wider With expiration, therefore, P2 may occur before with expiration and more closely split or single A2, with inspiration P2 moves toward it, resulting with inspiration. in close splitting, or a single second sound; with expiration the splitting is wider again.

Second Heart Sound

• Paradoxical splitting of S2 can occur with aortic outflow obstruction. • It is more likely to occur with hypertrophic cardiomyopathy than valvular aortic stenosis.

37 Atrial Septal Defect v/s Pulmonic Atrial Septal Defect v/s Pulmonic Stenosis Stenosis • Ostium secundum septal defect and a mild • The presence of left axis deviation on the EKG congenital pulmonic valve stenosis can have should be an immediate clue to change the both similar murmur and a wider split of the diagnosis of secundum defect to that of primum second sound that does not become single on defect. expiration. How to tell the difference? • Unless lead V1 on the EKG shows RSR1, right ventricular conduction delay, right bundle branch • Presence of a pulmonic systolic ejection sound block, or right ventricular hypertrophy, be immediately indicates pulmonic stenosis. cautious in making the diagnosis of atrial septal • The ejection sound may decrease in intensity or defect. disappear on inspiration. • The great majority of patients with atrial septal defect will have one of these findings.

Atrial Septal Defect v/s Pulmonic The Second Heart Sound: Stenosis Pulmonary Hypertension • Absence of a Systolic Murmur • As a rule, with pulmonary hypertension of a – The absence of a systolic murmur practically significant degree, the pulmonic component of rules out the diagnosis of uncomplicated the second sound becomes greatly accentuated ostium secundum atrial septal defect. and splitting usually becomes closer. • Pulmonary hypertension of this kind may occur with ventricular septal defect, atrial septal defect, , primary pulmonary hypertension, or recurrent pulmonary emboli.

The Second Heart Sound: Friction Rub Pulmonary Hypertension • The second heart sound becomes quite • A friction rub is usually best heard over the loud and easily palpable. third or fourth left sternal border using the • If pulmonary hypertension is associated diaphragm chest piece of the stethoscope with an atrial septal defect, more distinct pressed firmly against the chest wall. splitting of the second heart sound • Suspect acute pericarditis when a patient generally is heard and is one clinical clue says, “I have pain in my chest when I am to atrial defect. lying down, but I can get relief if I sit up and get in a certain position”.

38 Pericardial Knock Sound Pericardial Knock Sound

• The pericardial knock sound of constrictive • It may be misinterpreted as the opening pericarditis is present in the great majority of patients who have this condition, if one carefully snap of mitral stenosis. searches for it. • However, in timing it occurs later after the • This is a solid cardiac pearl aiding in the second sound than does the opening snap diagnosis. of a tight mitral stenosis, but earlier than • The knock sound is present in 90% or more of the normal physiological third heart sound patients with constrictive pericarditis. The sound occurs in the ventricle during the rapid filling or ventricular (S3) gallop. phase of early diastole and is probably produced by blood striking the ventricular walls.

How to differentiate the opening snap of mitral How to differentiate the opening snap of mitral stenosis from the pericardial knock sound of stenosis from the pericardial knock sound of constrictive pericarditis constrictive pericarditis • The diastolic murmur of mitral stenosis is • The first sound in mitral stenosis is usually usually heard over the point of maximum loud when the opening snap is heard. The impulse of the left ventricle. first sound associated with the pericardial • A diastolic murmur is hardly ever present knock is often not accentuated, although it can with constrictive pericarditis. be. • An exception: Very very rarely, • P2 is accentuated with mitral stenosis, but not constriction between the left atrium and with constrictive pericarditis. left ventricle has occurred, resulting in a diastolic murmur.

How to differentiate the opening snap of mitral stenosis from the pericardial knock sound of Coarctation of the Aorta constrictive pericarditis • Neck vein distention is characteristic of • The diagnosis of coarctation of the aorta constrictive pericarditis, but does not can generally be made by several simple usually occur with mitral stenosis. findings: • Rheumatic heart disease usually has two – Hypertension in the upper arms, a basal valves involved, the aortic and the mitral. systolic murmur, and decreased or absent femoral arterial pulsations. • This is not so with constrictive pericarditis.

39 Continuous Murmurs

• All that is continuous is not patent • Accessory coronary artery ductus. • Sinus of Valsalva fistula • Coronary arterial fistula • Dr. William Nelson of the University of • Systemic South Carolina has a list of the possible • Blalock-Taussig operation causes of continuous murmurs: • Potts operation – Patent ductus arteriosus • Waterson operation • Coarctation of the aorta – Aortic pulmonic window • Coarctation of the pulmonary artery – Truncus I-II-III • Pulmonary Thromboembolism – Anomalous origin of left coronary artery from the pulmonary artery

Continuous Murmurs Continuous Murmurs • -Arteritis • -Arteriosclerosis obliterans • A continuous innocent venous hum murmur • -Coronary “stenosis” in the neck is a common finding in children. • -Venous hum-neck • The patient should be in the sitting position (the • -Mammary hum – breast (pregnancy) hum’s origin is venous blood flow in the jugular • -Total anomalous pulmonary venous connection vein which empties into the right atrium). • -Coarctation collaterals • On auscultation, the right hand places the bell of • -Bronchial collaterals the stethoscope over the right supraclavicular fossa; the left hand holds the patient’s chin from • -Trucus-IV behind and tilts it upward and to the left. • -“Pseudo-truncus” • When an optimal position of the neck “on a • -Tricuspid atresia stretch” is reached, the hum, if present, will be • -Severe Tetralogy of Fallot heard. • -Cruveiller-Baumgarten Syndrome

Continuous Murmurs

• It frequently has the character of a continuous loud, low frequency roaring murmur, and it usually can be made to disappear by moving the head to the forward position. • Light pressure with the finger over the upper part of the jugular vein will cause the murmur to cease.

40 Venous Hum Venous Hum

• On careful examination of approximately 90 • Hyperthyroidism – The absence of a NFL players, a venous hum was detected in all. venous hum practically rules out • Remember that the venous hum is probably the hyperthyroidism. result of a degree of normal mild obstruction of venous blood flow in the jugular vein to the right side of the heart, heard with the bell of the stethoscope placed over the supraclavicular fossa, especially when the patient’s head is turned to the opposite direction and the neck is on a stretch.

S3 and S4 Prosthetic Valves

• • Multiple Systolic Sounds – Following a • Normal Variants: The absence of an S4 or valve replacement utilizing the Starr- S3 gallop may be helpful in evaluation of a Edwards ball valve, numerous systolic patient who has findings on the ECG sounds can be heard which might simulate suspicious for coronary artery disease, the rolling of dice on a hard surface or the myocarditis, or cardiomyopathy. flipping of a stick on a picket fence.

Prosthetic Valves Holosystolic Murmurs

• Porcine Valves • The murmur of ventricular septal defect is • An early to midsystolic murmur, usually grade 2 usually best heard along the lower left or 3, is a normal finding following successful sternal border, although there is radiation valve replacement with a porcine valve. of this murmur to the apex. • Prosthetic valve sounds are sometimes loud • The papillary muscle rupture is more likely enough that the patient can hear them, to have the murmur loudest at the apex, especially at night or other times when with radiation laterally to the left axillary everything is quiet. Sometimes other members lines. of the family also can hear the sounds. • Be sure to carefully search for a palpable thrill, for this may clinch the diagnosis.

41 Holosystolic Murmurs Pulmonary Hypertension

• A palpable systolic thrill along the left • Signs of pulmonary hypertension include: sternal border is characteristic of septal – A right ventricular lifting impulse along the perforation, whereas with papillary muscle lower left sternal border; rupture the palpable systolic thrill is more – A palpable pulmonic valve closure; likely localized over the apical area. – Possibly an A-wave detected on examination of the jugular venous pulse in the neck.

Pulmonary Hypertension Pulmonary Hypertension

• On auscultation there may be a loud • Syncope Due to Primary Pulmonary closely split second heart sound (which Hypertension might even be suspected on palpation), an – Any time a young woman has episodes of ejection sound in early systole that syncope always thing of primary pulmonary becomes fainter on inspiration might be hypertension. present, and with more advanced degrees of pulmonary hypertension, an atrial (S4) gallop might be heard in presystole.

From:

• Cardiac Pearls by W. Proctor Harvey • Cardiovascular Medicine Volume 2 by Eric Topol • Up to Date 2004 • Hurst’s The Heart Online Edition

42