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Home , Auscultation, Cannon A waves, Cardiac examination, Fourth heart sound, Jugular venous pressure, Palpation

The Wiggers Diagram CARDIOVASCULAR SYSTEM Mervyn Gotsman M.D.

Department of , Hadassah x y University Hospital, Hebrew University - Hadassah , Jerusalem, Israel

PHYSICAL EXAMINATION CARDIOVASCULAR SYSTEM CARDIOVASCULAR SYSTEM General examination • Walking and gait • General examination • Sitting or lying • Arterial – brachial, • Orthopnoea carotids, peripheral • (central or peripheral), anaemia, • jaundice • Fever and embolic signs • The • • • Right (JVP, dependent oedema, • Inspection hepatomegaly, , pleural effusions) • • Left heart failure (dyspnoea, tachypnoea, • orthopnoea, , basal crepitations • Pulmonary • • Sytemic disease: thyrotoxicosis, scleroderma, lupus erythematosis, etc

Left Heart Failure Right Heart Failure •Elevated LVEDP • LAP JVP • PVP •Pulmonary congestion Hepar •Dyspnoea Ascites •Orthopnoea •Cough Ankle •Tiredness and lethargy Weight

1 PHYSICAL EXAMINATION AArterialrterial pulse CARDIOVASCULAR SYSTEM Radial

• Arterial pulse • Jugular Venous Pressure • : • Inspection • Palpation • Percussion • Auscultation

Arterial pulse 120 Arterial pulse

Radial artery 80 Carotid artery Amplitude/Contour: • : ( 60-100 ). • Hypokinetic ↓ ( weak ) - • Rhythm: Regular 120 Irregular: Sinus Heart failure Occasional - Premature beats 80 - Dropped beats • Hyperkinetic ↑ increased volume Totally - irregular 120 Fever, anemia, hyperthyroidism

80 AR, , atherosclerosis

Arterial pulse: Carotid artery Pulsus parvus et tardus Amplitude/Contour: The phono-carotid • Bisferiens - HOCUM pulse tracing: • Collapsing – AR • Phono – Long systolic ejection • Parvus et tardus - AS murmur – Paradoxical split of the • Alternans - Heart failure 2nd heart sound • Carotid pulse tracing • Bigeminal - Premature beats – Pulsus parvus et tardus • Paradoxical - Pericardial tamponade - Constrictive • Dicrotic – Cardiomyopathy • Filiform -

2 Jugular Venous Pressure PHYSICAL EXAMINATION 45o angle CARDIOVASCULAR SYSTEM • Arterial pulse • Jugular Venous Pressure • The heart • Inspection • Palpation • Percussion • Auscultation

Jugular Venous Pressure Jugular Venous Pressure

Patient at 30 degrees and oblique lighting Differentiation from arterial pressure • Two waves ( if not in A fib) • Changes with position • Obliterated with pressure • Decreases with respiration

Jugular Venous Pressure Jugular Venous Pressure • Reflects – – volume – Tricuspid valve – Diastolic events in the right • Estimate CVP Maximal 3cm from sternal angle + 5cm from (Right atrial pressure) External jugular Venous Pressure • Increased pressure Right sided heart failure Internal jugular Constrictive pericarditis vein Tricuspid stenosis Obstructed SVC Increased intrathoracic pressure

3 Jugular Venous Pressure Jugular Venous Pressure

av wave

x y descent S1 S2 S1 S2

Angle of Lewis

Jugular Venous Pressure Jugular Venous Pressure Diagnosis ?

• Amplitude of pulsations a wave, x descent, v wave, y descent Atrial contraction, relaxation, atrial filling, emptying • Absent ‘a’ wave - • Giant ‘a’ wave - tricuspid Stenosis, PHT • Cannon ‘a’ waves - AV dissociation • Large ‘v’ wave - tricuspid regurgitation • Slow ‘y’ descent – tricuspid stenosis

Jugular Venous Pressure ? Diagnosis תמונה מס' 1 מראה

• גל תות ח • גל A גבו ה • גל V ב ולט • יר ידת ' Y ' חז קה

4 Jugular Venous Pressure תמונה מס' 2 מראה:

• Hepatojugular reflux - Sustained rise of • א. הצר ות של ה מסתם ה ות ינ י . JVP Heart failure. ב. הצר ות של המ סתם ה ד ו -צנ יפ י . • Kussmaul’s sign - Increase with inspiration ג. ית ר לח ץ דם ר יאת י. Constrictive pericarditis ד. א י ס פ יקה של ה מסתם התלת - Heart failure צניפ י

PHYSICAL EXAMINATION CARDIOVASCULAR SYSTEM

• Arterial pulse • Jugular Venous Pressure • Cardiac Examination • Inspection • Palpation • Percussion • Auscultation

5 Cardiac Examination: Inspection Cardiac Examination: Inspection

Cardiac pulsations PMI Parasternal lift S3, S4 Dyskinesis Aneurysm

PHYSICAL EXAMINATION: Cardiac Examination: Palpation CARDIOVASCULAR SYSTEM

• Arterial pulse Areas of palpation • Jugular Venous Pressure • Apical impulse (PMI) • Cardiac Examination • Left sternal border • Inspection • Left and right 2nd interspace • Palpation • Epigastric area • Percussion • Thrills • Auscultation

Cardiac Examination: Palpation Cardiac Examination: Palpation

• Apical impulse (PMI) • Apical impulse (PMI)

6 Cardiac Examination: Palpation Cardiac Examination - Palpation Left parasternal lift • Right ventricular volume load – ASD – Pulmonary incompetence – Tricuspid incompetence - see-saw motion • Right ventricular pressure load – Pulmonary – Pulmonary stenosis • Left atrial lift Apical impulse (PMI) • – Mitral incompetence

Cardiac Examination: Palpation Cardiac Examination: Palpation

• Left 2nd interspace - Pulmonic: PHT • Right 2nd interspace - Aortic: HTN • Epigastric area - Right ventricle in hyperinflated • Thrills - Murmurs grade 4+

• Left sternal border - Right ventricle

The normal apex-cardiogram Apexcardiogram in aortic stenosis The normal apex cardiogram: • Normal outward motion fills the first third of • Prominent outward systole presystolic motion • Small presystolic outward motion • Prolonged sustained • Rapid filling wave RFW outward motion fills all of systole ‘a’

7 Apexcardiogram in aortic stenosis תמונה מס' 4 מראה

• Prominent outward א. ח וד מ ו סט שמאלה . presystolic motion ב. ח ו ד עם ה ולם מא ורך . Prolonged sustained • outward motion fills ג. ד ופק מת מ וטט. all of systole ד. הר מה של חדר ימנ י .

PHYSICAL EXAMINATION Cardiac Examination: Auscultation CARDIOVASCULAR SYSTEM Auscultation • Arterial pulse Areas of auscultation • Jugular Venous Pressure Apex • Cardiac Examination • • Inspection • Left Sternal Border • Palpation • Aortic • Percussion • Pulmonic • Auscultation

Cardiac Examination: Auscultation Cardiac Examination: Auscultation

Areas of auscultation: Apex Areas of auscultation: Left Sternal Border

8 Cardiac Examination: Auscultation Cardiac Examination: Auscultation

Stethoscope • Diaphragm ( high pitched ) - S1, S2, AR, MR, clicks, friction rubs • Bell ( low pitched ) - S3, S4, MS. Position • Left decubitus - S3, S4, mitral sounds ( MS ) Areas of auscultation: Aortic, Pulmonic • Lean forward and exhale - Aortic (AR)

Cardiac Examination: Auscultation Cardiac Examination: Auscultation

Lean forward and exhale Left decubitus

The Wiggers Diagram Cardiac Examination: Auscultation • First heart sound (S1): Closure of Mitral and Tricuspid valves

S1 S2 S1 S2

x y

MMT T Systole Diastole

9 Cardiac Examination: Auscultation Cardiac Examination: Auscultation First heart sound (S1) • Intensity Second heart sound (S2): – LV dp/dt • Second heart sound (S2): – P-R interval • Short PR – loud Closure of Aortic and Pulmonic • Long PR - soft • Accentuated: valves – Short PR interval S1 A2 P2 S1 A2 P2 – high states – MS Expiration Inspiration • Diminished – 1st degreeAVB, – MR. Systole Diastole • Splitting – RBBB Normal – VPB’s.

Cardiac Examination: Auscultation Cardiac Examination: Auscultation • Second heart sound (S2): • Second heart sound (S2): Closure of Aortic and Pulmonic Closure of Aortic and Pulmonic valves valves S1 A2 P2 S1 A2 P2 S1 P2 A2 S1 A2 P2

Expiration Inspiration Expiration Inspiration

Systole Diastole Systole Diastole Normal but wide Reversed splitting

Cardiac Examination: Auscultation Cardiac Examination: Auscultation Third heart sound ( S3 ) • Second heart sound (S2-A2, P2) • Sudden expansion of the ventricle by rapid • Single- common ventricle or truncus, valve ventricular filling atresia Often palpable • Fixed splitting - ASD • • Splitting is due to differences in LV and RV • Physiological in young people and during exercise systolic duration • Pathological in and heart failure • RVET>LVET • Wider splitting S S S3 S S S3 – Longer RVET - overloading 1 2 1 2 – Shorter LVET - underloading • Paradoxical splitting – Longer LVET -overloading – Shorter RVET -underloading Systole Diastole

10 Cardiac Examination: Auscultation Cardiac Examination: Auscultation ( S4 ) Fourth heart sound ( S4 ) • Sudden expansion of the ventricle • Physiological in athletes, older people (right or left) by atrial contraction • Pathological due to decreased compliance Physiological in athletes, older people. • Physiological in athletes, older people. (thick wall or poor relaxation • Pathological due to decreased Pressure overload - HTN, AS compliance (right or left ventricle) S1 S2 S4 S1 S2 Ischemia, Cardiomyopathies • Right sided S4: pressure overload ( PS, PHT ) Systole Diastole • Accentuated by exercise

Cardiac Examination: Auscultation Cardiac Examination: Auscultation

Extra systolic sounds: Ejection sound : Left or • Ejection sound right – Aortic Valve stenosis – Pulmonary • Midsystolic click • Increased blood flow • through the valve • Prolapse • • Arterial hypertension Extra diastolic sounds: • Dilatation of the artery • Opening snap • Mitral Stenosis

Cardiac Examination: Auscultation Cardiac Examination: Auscultation Extra systolic sounds: Extra systolic sounds: • Ejection sound: Aortic Stenosis • Ejection sound: Aortic Stenosis

Ej Ej S1 S2 S1 S2 S1 S2 S1 S2

Systole Diastole Systole Diastole

11 Cardiac Examination: Auscultation Cardiac Examination: Auscultation Extra systolic sounds: Extra systolic sounds: • Ejection sound: Aortic Stenosis • Midsystolic click:

Ej Cl S1 S2 S1 S2 S1 S2 S1 S2

Systole Diastole Systole Diastole

Cardiac Examination: Auscultation Cardiac Examination: Auscultation Extra diastolic sounds: Murmurs: • Opening snap: Mitral or tricuspid stenosis • Timing - Systolic - ( mid, pan ) Diastolic - ( early, mid, late ). Severe stenosis – shorter 2-os interval • Severe stenosis – shorter 2-os interval • Shape - crescendo, decrescendo, plateau. • Location • Radiation - Axilla, Back,Suprasternal notch OS S1 S2 S1 S2 • Intensity ( 1 - 6 ). • Pitch • Quality - blowing, harsh, rumbling, musical • Changes with physiological interventions – Systole Diastole exercise, standing, squatting, Valsalva

Cardiac Examination: Auscultation Cardiac Examination: Auscultation Murmurs: Murmurs: • Ejection: Left and right ventricular • Ejection: Left and right ventricular outflow tract stenosis (subvalvular, outflow tract stenosis (subvalvular, valvular, ring, supravalvular) valvular, ring, supravalvular)

S1 S2 S1 S2 S1 S2 S1 S2

Systole Diastole Systole Diastole

12 Aortic stenosis Aortic stenosis - murmur

The normal apex-cardiogram Apexcardiogram in aortic stenosis The normal apex cardiogram: • Normal outward motion fills the first third of • Prominent outward systole presystolic motion • Small presystolic outward motion • Prolonged sustained • Rapid filling wave RFW outward motion fills all of systole ‘a’

Apexcardiogram in aortic stenosis

• Prominent outward presystolic motion • Prolonged sustained Pulmonary outward motion fills all of systole stenosis

13 Right ventricular outflow tract stenosis Hypertrophic myopathy

Interventricular septum

Abnormal mitral valve chordae

HOCUM Mitral incompetence

Large ‘a’ wave Double pulse

Systolic ejection Double apex murmur

Response of murmur

Cardiac Examination: Auscultation Cardiac Examination: Auscultation Murmurs: Severe MR • Pansystolic: Mitral, Tricuspid Regurgitation, Ventricular septal defect

S A P S S 1 2 2 S3 1 2 S1 S2 S1 S2

Systole Diastole Systole Diastole

14 Cardiac Examination: Auscultation :Murmurs תמונה מס' 5 מראה: • Mid-diastolic+presystolic Mitral, tricuspid stenosis – הדבר שאנ ו ה ב ולט בא י ספ יקה קשה של המסתם Mid diastolic flow murmurs • הד ו -צנ יפ י הם: א- אי ושה פ ן ס יסט ול ית . S1 S2 S1 S2 ב- פיצ ול רחב של הק ול השני. ג- קול של ישי . ד- קול רב יע י ח זק. Systole Diastole

Cardiac Examination: Auscultation Mitral stenosis 1. Opening snap Mitral stenosis 2. Mid-diastolic murmrur 3. Presystolic accentuation Ring 4. Loud first heart sound Cusps S S OS S S 1 2 1 2 Chordae Papillary muscles

Systole Diastole

A P 22 22 Auscultatory

S S S 11 22 11 Signs OS A P 22 22 MDM PSM Mild Stenosis S11 S22 S11 OS A22P22

Severe Stenosis S11 S22 S11

A22P22

Calcific Valve S11 S22 S11 OS A P 22 22 MDM Atrial Fibrillation S11 S22 S11

15 תמונה מס' 6 מראה:

Mitral stenosis • מה אינו נכון ? א. הצרות המס תם הדו -צניפי - הפס קה בין איוושה אמצע דיאסטולית ופרי סיסטולית, מראה ש ההצרות קלה מאד . Ring ב. הע דרות של צליל פ תיחת ה מסתם מראה מסתם מסויד. Cusps ג. ה מרחק בין הקול השני וצליל פתיחת המסת ם מ תערך עם חומרת ההצרות. Chordae ד. עוצמת הקול השני (חלק הריאתי) מגדיר את החומרה של Papillary muscles יתר לחץ דם ריאתי וכן חומרת הצרות ה מסתם

Cardiac Examination: Auscultation Cardiac Examination: Auscultation Murmurs: Murmurs: • Early diastolic • Early diastolic – – mild, severe – Aortic insufficiency – Pulmonary insufficiency – Pulmonary insufficiency

S1 S2 S1 S2 S1 S2 S1 S2

Systole Diastole Systole Diastole

Cardiac Examination: Auscultation Cardiac Examination: Auscultation Murmurs: • Early diastolic Special physiological maneuvers: – Aortic insufficiency • Squatting - – Pulmonary insufficiency venous return ↑ , ↑ -LV volume ↑ Murmurs of MVP ↓, HOCM ↓, AS ↑ Valsalva, Standing S1 S2 S1 S2 • The opposite effect • Inspiration – increase in right sided flow and event Systole Diastole – decrease in left sided flow and events

16 Cardiac Examination: Auscultation Murmurs: • Continuous – Patent ductus arteriosus – Aortopulmonary window – Arterio-venous fistula – Ruptured sinus of Valsalva

S1 S2 S1 S2

Systole Diastole

17