The Wiggers Diagram PHYSICAL EXAMINATION CARDIOVASCULAR SYSTEM Mervyn Gotsman M.D. Department of Cardiology, Hadassah x y University Hospital, Hebrew University - Hadassah Medical School, Jerusalem, Israel PHYSICAL EXAMINATION CARDIOVASCULAR SYSTEM CARDIOVASCULAR SYSTEM General examination • Walking and gait • General examination • Sitting or lying • Arterial pulse – brachial, • Orthopnoea carotids, peripheral • Cyanosis (central or peripheral), anaemia, • Jugular Venous Pressure jaundice • Fever and embolic signs • The heart • • • Right heart failure (JVP, dependent oedema, • Inspection hepatomegaly, ascites, pleural effusions) • Palpation • Left heart failure (dyspnoea, tachypnoea, • Percussion orthopnoea, cough, basal crepitations • Pulmonary disease • Auscultation • 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 Edema •Tiredness and lethargy Weight 1 PHYSICAL EXAMINATION AArterialrterial pulse CARDIOVASCULAR SYSTEM Radial artery • Arterial pulse • Jugular Venous Pressure • Cardiac Examination: • Inspection • Palpation • Percussion • Auscultation Arterial pulse 120 Arterial pulse Radial artery 80 Carotid artery Amplitude/Contour: • Heart rate: ( 60-100 ). • Hypokinetic ↓ ( weak ) - Hypovolemia • Rhythm: Regular 120 Irregular: Sinus arrhythmia Heart failure Occasional - Premature beats 80 Aortic stenosis - Dropped beats • Hyperkinetic ↑ increased stroke volume Totally - irregular 120 Fever, anemia, hyperthyroidism 80 AR, bradycardia, 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 pericarditis • Dicrotic – Cardiomyopathy • Filiform - shock 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 – Right atrial pressure – Blood volume – Tricuspid valve – Diastolic events in the right ventricle • Estimate CVP Maximal 3cm from sternal angle + 5cm from atrium (Right atrial pressure) External jugular Venous Pressure • Increased pressure vein 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 Systole Diastole 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 - atrial fibrillation • 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 hypertension – 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 lungs • 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 cardiac output 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 volume overload 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 Fourth heart sound ( 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 • Mitral 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: