PhysicalPhysical ExamExam PartPart IIII University of Michigan Cardiovascular Center KimKim A.A. Eagle,Eagle, MDMD AlbionAlbion WalterWalter HewlettHewlett ProfessorProfessor DirectorDirector PhysicalPhysical Exam:Exam: PartPart IIII • Heart Sounds • Heart Murmurs HEARTHEART SOUNDSSOUNDS S1S1 • MITRAL + TRICUSPID CLOSURE (M1, T1) • WIDE SPLITTING: RBBB, EBSTEIN’S S2S2 • AORTIC + PULMONIC CLOSURE (A2, P2) • WIDE, PHYSIOLOGIC SPLITTING: RBBB, MR • REVERSED (PARADOXICAL) SPLITTING: LBBB, RV PACING, SEVERE AS, HOCM, ISCHEMIA • FIXED SPLITTING: ASD • PULMONARY HTN: LOUD, SINGLE S2 S3S3 /S4/S4 GallopGallop SoundsSounds DIASTOLICDIASTOLIC SOUNDSSOUNDS • S3 (“proto-diastolic”) reliable indicator of LV systolic dysfunction with prognostic relevance • S4 (“pre-systolic”) associated with ↑ LVEDP Drazner MH, et al. NEJM 2001;345:574 HEARTHEART SOUNDSSOUNDS SystolicSystolic ClicksClicks •• EjectionEjection:: TimingTiming isis coco--incidentincident withwith carotidcarotid upstrokeupstroke ExamplesExamples:: Ao/PulmAo/Pulm clickclick (ES)(ES) •• NonNon--ejectionejection:: OccursOccurs afterafter carotidcarotid upup-- strokestroke ExampleExample:: MVPMVP HEARTHEART SOUNDSSOUNDS AdventitiousAdventitious DiastolicDiastolic SoundsSounds •• OpeningOpening snapsnap ofof mitralmitral stenosisstenosis P2P2--OSOS intervalinterval inverselyinversely relatedrelated toto LALA--LVLV pressurepressure gradientgradient •• PericardialPericardial knockknock •• TumorTumor plopplop (myxoma)(myxoma) HEARTHEART MURMURSMURMURS SystolicSystolic HeartHeart MurmursMurmurs EarlyEarly:: AcuteAcute MR,MR, TRTR withwith normalnormal PAPA pressurespressures SettingsSettings:: AcuteAcute MIMI (Inf/Post(Inf/Post >> Ant)Ant) EndocarditisEndocarditis RupturedRuptured chordaechordae AcuteAcute vs.vs. ChronicChronic MRMR HEARTHEART MURMURSMURMURS SystolicSystolic HeartHeart MurmursMurmurs MidMid--systolic/Ejection:systolic/Ejection: BenignBenign LeftLeft--sided:sided: AS,AS, HOCM,HOCM, otherother RightRight--sided:sided: PSPS LVOTLVOT OBSTRUCTIONOBSTRUCTION FINDINGFINDING ASAS SASSAS DMSDMS HOCMHOCM Post-VPB PP ↑ ↑ ↑ ↓ AR + - + - S4 + - - + Paradox S2 + - - + EC + - - - Location 2RIS 1RIS 2RIS 4LIS Carotid ↓ R>L + ↑ AS= aortic stenosis DMS= discrete, membranous AS SAS= supra-valvular AS HOCM= hypertrophic obstructive cardiomyopathy PP= pulse pressure VPB= ventricular premature beat EC= ejection click IS= interspace HEARTHEART MURMURSMURMURS CaveatsCaveats withwith AorticAortic StenosisStenosis •• Elderly:Elderly: preservedpreserved carotidscarotids •• LowLow output:output: ↓↓ intensityintensity •• ConfusionConfusion withwith MR:MR: GallarvardinGallarvardin effecteffect ↑↑ IntensityIntensity postpost--VPBVPB HEARTHEART MURMURSMURMURS SystolicSystolic HeartHeart MurmursMurmurs - MidMid--late:late: MVPMVP (+/(+/-- click)click) -- DifferentialDifferential radiationradiation withwith leafletleaflet prolapseprolapse oror flail:flail: posteriorposterior leafletleaflet ante.ante. radiationradiation anterioranterior leafletleaflet post.post. radiationradiation HEARTHEART MURMURSMURMURS SystolicSystolic HeartHeart MurmursMurmurs Holosystolic/Plateau:Holosystolic/Plateau: ChronicChronic MRMR ChronicChronic TRTR VSDVSD HEARTHEART MURMURSMURMURS DIASTOLICDIASTOLIC MURMURSMURMURS EARLY • AR • PR (GRAHAM STEELL) MID • MS (ASSOCIATED FINDINGS) • TS • FILLING COMPLEX (R or L) WITH LARGE VOLUME LOAD DUE TO MR, TR, or ASD • MYXOMA HEARTHEART MURMURSMURMURS DIASTOLICDIASTOLIC MURMURSMURMURS AorticAortic RegurgitationRegurgitation (AR)(AR) LL >> RR sternalsternal radiationradiation withwith valvevalve vs.vs. rootroot dis.dis. AcuteAcute ARAR :: soft,soft, earlyearly diastolicdiastolic murmurmurmur ChronicChronic AR:AR: classicclassic highhigh pitched,pitched, decrescendodecrescendo PulmonicPulmonic RegurgitationRegurgitation (PR)(PR) WithWith severesevere PAPA HTNHTN (loud(loud P2,P2, GrahamGraham Steell)Steell) AfterAfter repairrepair ofof TOF:TOF: lowlow pitched,pitched, softsoft HEARTHEART MURMURSMURMURS CONTINUOUSCONTINUOUS MURMURSMURMURS •• PDAPDA •• RupturedRuptured SinusSinus ofof ValsalvaValsalva aneurysmaneurysm •• AVAV fistulafistula (Coronary,(Coronary, other)other) •• CervicalCervical venousvenous hum,hum, mammarymammary soufflesouffle QUESTIONQUESTION ForFor whichwhich ofof thethe followingfollowing combinationcombination ofof findingsfindings wouldwould CTCT assessmentassessment ofof thethe ascendingascending aortaaorta bebe indicatedindicated ?? A.A. MidMid--systolicsystolic clickclick atat thethe apexapex withwith aa midmid--latelate gradegrade 22 systolicsystolic murmur.murmur. B.B. LateLate systolicsystolic clickclick atat thethe lowerlower leftleft sternalsternal borderborder C.C. EarlyEarly systolicsystolic clickclick atat thethe lowerlower leftleft sternalsternal borderborder withwith aa gradegrade 11 diastolicdiastolic murmurmurmur alongalong thethe leftleft sternalsternal border.border. D.D. EarlyEarly systolicsystolic clickclick atat thethe 22nd LICSLICS withwith aa gradegrade 22 midmid--sytolicsytolic murmur.murmur. ClickClick becomesbecomes softersofter onon inspiration.inspiration. DynamicDynamic AuscultationAuscultation RespirationRespiration ↑↑ RR--sidedsided murmursmurmurs ↓↓ LL--sidedsided murmursmurmurs ExampleExample:: TRTR (Carvalho(Carvalho’’ss sign)sign) ExceptionException:: pulmonicpulmonic valvevalve clickclick DynamicDynamic AuscultationAuscultation ValsalvaValsalva ManueverManuever ↓↓ venousvenous return,return, ↓↓ preload,preload, ↑↑ afterloadafterload ExamplesExamples HOCM:HOCM: ↑↑ obstruction,obstruction, ↑↑ murmurmurmur AS:AS: ↓↓ preload,preload, ↓↓ murmurmurmur MVP:MVP: ↓↓ preload,preload, ↑↑ murmurmurmur DynamicDynamic AuscultationAuscultation Standing/SquattingStanding/Squatting Standing:Standing: rapidrapid ↓↓ preload/afterloadpreload/afterload Squatting:Squatting: rapidrapid ↑↑ preload/afterloadpreload/afterload ExampleExample HOCM:HOCM: standstand:: ↑↑ murmurmurmur squatsquat:: ↓↓ murmurmurmur DynamicDynamic AuscultationAuscultation Standing/SquattingStanding/Squatting Standing:Standing: rapidrapid ↓↓ preload/afterloadpreload/afterload Squatting:Squatting: rapidrapid ↑↑ preload/afterloadpreload/afterload ExampleExample MVP:MVP: standstand:: click/murmurclick/murmur closercloser toto S1,S1, ↑↑ murmurmurmur squatsquat:: click/murmurclick/murmur awayaway fromfrom S1,S1, ↓↓ murmurmurmur DynamicDynamic AuscultationAuscultation MVPMVP DynamicDynamic AuscultationAuscultation HandHand Grip/4Grip/4 ExtremityExtremity BPBP CuffCuff ↑↑ afterloadafterload ExamplesExamples MR:MR: ↑↑ murmurmurmur VSD:VSD: ↑↑ murmurmurmur QUESTIONQUESTION WhichWhich ofof thethe followingfollowing murmursmurmurs decreasesdecreases inin intensityintensity duringduring thethe ValsalvaValsalva maneuver?maneuver? A.A. ChronicChronic mitralmitral regurgitationregurgitation B.B. AorticAortic stenosisstenosis C.C. HOCMHOCM D.D. MVPMVP.