Physical examination of the heart 3rd Medical Department Tamás FENYVESI M.D. 2018, 3rd year 1 n Inspection n Palpation n percussion n auscultation ! n (echocardiography!!) The heart is a generator of vibrations from "0" to about 2000 Hz 2 Inspection of the face: „For by his face straight shall you know his heart” Shakespeare, King Richard III Act III, scene IV-53 3 4 Inspection of the precordium observe from the foot, patients head and trunk elevated 300 chest abnormalities: 5 Inspection of the chest chest abnormalities: barrel shaped – emphysema pectus excavatum-”caved-in”sternum carinatum- bulging of the sternum 6 excavatum, funnel carinatum, pigeon (a Latin term meaning a protrusion of the hollowed chest ) sternum and the ribs 11/5/2018 7 Precordial pulsations due to the heartbeat Areas of inspection and palpation • The sternoclavicular area • The aortic area • The pulmonic area • The right ventricular (left parasternal) area • The apical (left ventricular area) • The epigastric area • Ectopic ( variable-location) areas 8 Palpation Movements felt on the chest surface, frequency below 15-20 Hz –Cardiac apex impulse -5th interspace, midclav nantihoral rotation of the heart in early systole and tapping of the apex on the chest wall 9 LV Segmentation and Mechanics in HCM: Twisting the Rubik’s Cube Into Perfection! JACC Cardiovasc Imaging 2012;5:765 10 –Characteristics of the impulse : amplitude, – duration(sustained), –direction(e.g.outward during systole abnormal), – time, – quickness, – location, – distribution 11 Normal findings (figure) Apex impulse (left ventricular thrust) the point of maximal outward movement nminimal amplitude, brief in duration, outward in early systole , midclav.line 5th interspace, small area:2-3 cm diameter –Parasternal retraction: the lower parasternal area moves inward during systole , due to volume change during ejection (sustained) 12 left ventricular impulse 13 nAbnormal findings Left ventricular hypertrophy:exaggeration of LV thrust-amplitude, duration,dysplacement n pressure load :aortic stenosis n volume load :aortic insuff-amplitude+, sustained, mid and late syst.retraction 14 nAbnormal findings Right ventricular hypertrophy: sustained systolic lift lower parasternal region("V2„) most often mitral stenosis 15 nteriorn wall of the right ventr icle 16 –Ischaemic heart disease: outward paradox bulge of LV during systole, sustained, wide area, t infarction and angina- dyskinesis, akinesis 17 valvular heart disease t mitral stenosis: parasternal lift due to elevated pulmonary pressure t mitral incompetence: the thrust increased in amlitude occasionally second systolic peak - LV volume overload 18 –HOCM(IHSS) hypertrophic obstructive cardiomyopathy:double outward movement -a rocking sensation nPalpable heart sounds: hyperdynamic state-accentuated S1 nThrills :vibrations from loud murmurs low frequency (a cot’s purr) fremissement cattaire кошачье мурлыканье 19 Percussion of the heart is of limited value, on the surface of the chest from resonance to dullness. In old textbooks you find: relative and absolute dullness . left border within the left midclavicular line compare with the impulse location 20 Auenbrugger , Leopold „Inventum novum ex percussione thoracis …” 1761 He found that with light percussion of the chest , he could make a guess on the character and position of the organs in the chest. He learned in his father’s wine cellar that by percussion of the barrels one can determine the level of wine. He applied this to the heart! 21 Auenbugger 1761 Corvisart 1808 „direct” percussion Piory 1828 „indirect” use of plessimeter relative dullness absolute dullness 22 nThe outer limits of cardiac dullness –1.to the left when the diaphragm is higher –2.within the midclav.line in concentric hypertrophy –3.displacement to the right in left sided PTX or right sided atelectasis (collapse of the lung) 23 Percussion of the heart 24 –4.situs inversus –5.historic significance : valvular diseases before the invention of X-ray 25 Percussion in Luisada: Cardiology 1959 5½ pages In Braunwald 9th ed 2012 the term not even mentioned in the index 26 27 28 Auscultation of the heart nFirst discussed in HARVEY's De motu cordis 1628 nfetal heart sounds : Marsac 1680 -ridiculed nancient Egypt ?!! nAuscultation: Corvisart~1810 "immediate" auscultation Laennec 1816 "mediate" auscultation a rolled quire of paper "stethoscope“ a young female patient… 29 The first English remark on the Laenec mediate auscultation in 1829 John Forbes wrote: “Notwithstanding its value, I am extremely doubtful, because its beneficial application requires much time, and gives a good deal of trouble both to the patient and the practitioner.” 30 . The human ear is most sensitive to vibrations between 1000-4000 Hz heart sounds: 30-1000 Hz diaphragm for high frequency bell for low freq n Quiet room, n comfortable temperature, n exposure of the patient to the waist 31 11/5/2018 32 Fenyvesi The stethoscope nearpiece nrubber tubing:short,thick nbell ndiapragm Which is the most important component? nRapaport-Sprague n Littmann 33 34 Binaural stethoscope 11/5/2018 35 Camman 1852 The first binauricular stethoscope 11/5/2018 36 Bartlett 1880 11/5/2018 37 11/5/2018 38 11/5/2018 39 11/5/2018 40 . Phonocardiography : graphic (analogue) record of the heart sounds and murmurs, synchronized with ECG. Significance in timing and teaching. rarely used ? 11/5/2018 41 11/5/2018 42 52 Areas of auscultation n1.aortic: primary 2nd right interspace secondary 3rd left interspace adjecent to the sternum n 2.pulmonary :2nd left interspace n 3.tricuspid :4th-5th interspace left sternal border n 4.mitral : cardiac apex 11/5/2018 43 11/5/2018 44 11/5/2018How to learn and practice auscultation 45 Beware, these are not advertisements of products, but just a teaching aid 46 Point-of-care ultrasound…NEJM 2014;370:1083 47 Carefully performed clinical studies have shown that diagnostic ultrasonography can be superior to the physical exam. In one study, first-year medical students using point-of-care ultrasound outperformed board-certified cardiologists using bedside cardiovascular physical examination in identifying cardiac abnormalities, identifying 75% of conditions, as compared with 49% identified by the cardiologists . NEJM 2014;370:1083 48 Areas of auscultation This is orientative-systematic approach, so called "inching“ is of great use In each area listen to sounds and murmurs – 11/5/2018 49 Heart sounds: brief auditory vibrations characterized by • intensity (loudness) • frequency (pitch) • quality (timbre) 11/5/2018 50 Heart murmurs: auditory vibrations more prolonged than a sound, characterized by • timing in the cardiac cycle • intensity • frequency • configuration (shape) • duration • direction of radiation 11/5/2018 51 In each area listen to sounds and murmurs – S1,S2 :intensity,constancy,splitting – extra sounds:in systole ,in diastole nOpening and closing of the valves: high frequency nFilling sounds: low frequency 11/5/2018 52 11/5/2018 53 The FIRST HEART SOUND, S1 –main components M1 and T1 closure tcoincident with the coaptation, but not clapping together- rather halting of the blood --vibration of the "cardiohemic" system –splitting of S1 (not audible) – RBBB M1T1 – RV pacing T1M1 "reversed splitting" – or ectopics 11/5/2018 54 Intensity of S1: 1. integrity of the valve closure 2. mobility of the valve 3. velocity of closure: LV pressure rise in early syst 11/5/2018 55 Intensity of S1 depends on the mitral component (M1) with shorter PR at the beginning of LVP rise the mitral leaflets are wide apart, M1 is delayed and coincides with a higher velocity of LV pressure rise: velocity of closure long PR-----mild soft S1 short PR---- loud S1 11/5/2018 56 Hemodynamic correlates of the S1: the first high frequ component of the S1 is delayed from LV-LA pressure crossover by 30 ms (inertial flow) aa 11/5/2018 57 E A mitral leaflet motion ECG T P R 11/5/2018 58 complete AV block Long PR inteval Short PR interval soft S1 laud S1 11/5/2018 59 Intensity of S1 4.status of ventricular contractility 5.transmission characteristics of the thorax 11/5/2018 60 S1 in pathologic conditions in mitral stenosis:loud ,late M1 increased left atrial pressure 1.it delays A-V pressure crossover, it occurs at a higher dP/dt 2.prevents "preclosure " of the valves 11/5/2018 61 Fenyvesi decreased intensity of M1 LBBB LV dysfunction acute aortic regurgitation- early "preclosure" of the mitral valve 11/5/2018 62 Go to video (ICI ausc1). 11/5/2018 63 Ejection sounds Aortic valvular: nonstenotic congen.bicuspid stenosis p.m.at the apex, timing: anacrotic notch of the upstroke of the aortic pressure pm.aorta aortic vascular : sclerotic aortic root Pulmonary valvular: decreases with inspi- ration pulmonary vascular: dilatation 11/5/2018 64 Aortic ejection sound 11/5/2018 65 Pulmonic ejeciton sound Accentuated pulm2 Opening snap 11/5/2018 66 NONEJECTION SOUNDS systolic click: prolapse of the mitral valve pm.apex, timing: increased LV volume--- shift to S2(squatting,supine, vasopressor) decreased LV volume shift to S1(standing,Valsalva, amylnitrite) 11/5/2018 67 The second heart sound, S2 n" the key to auscultation of the heart" Leatham n A2-aortic pressure incisure n P2-pulmonic pressure incisure nA2 and P2 coincide with the complete closure of aortic and pulmonic valve leaflets. Not "clapping", but deceleration of the blood column n Delay from the ventricular pressure drop to the incisure :"hangout" pulmonary longer 11/5/2018 than aortic 68 11/5/2018 69 Splitting of S2 nNormal"physiological"splittig: