Cardiac Exam II 16 October 2018

Goals Continue to add meaning to your cardiac examination Incorporate immediate reinforcement via simulation (Harvey)

Objectives Understand the causes and timing of S3 Compare common causes of systolic murmurs (continued) Distinguish innocent/physiologic from pathologic murmurs Distinguish common diastolic murmurs and sounds Identify the pericardial friction rub Delineate techniques for accentuating murmurs

Diastolic Adventitious Sounds S3 and S4 Bates' Guide to Physical Examination and History Taking, 11e, 2012

Causes of S3 Rapid deceleration of blood against ventricular wall May be normal in healthy children and young adults Left or right ventricular dysfunction High volume Mitral/tricuspid regurgitation High flow Anemia Thyrotoxicosis Pregnancy Bates' Guide to Physical Examination and History Taking, 11e, 2012

Causes of S3 Rapid deceleration of blood against ventricular wall May be normal in healthy children and young adults Left or right ventricular dysfunction High volume Mitral/tricuspid regurgitation High flow Anemia Thyrotoxicosis Pregnancy Bates' Guide to Physical Examination and History Taking, 11e, 2012

Causes of S4 Audible atrial contraction Marker of change in ventricular compliance Associated with stiff ventricle Hypertrophic ventricle Hypertension Aortic stenosis Hypertrophic cardiomyopathy Acute myocardial ischemia Bates' Guide to Physical Examination and History Taking, 11e, 2012

Causes of S4 Audible atrial contraction Marker of change in ventricular compliance Associated with stiff ventricle Hypertrophic ventricle Hypertension Aortic stenosis Hypertrophic cardiomyopathy Acute myocardial ischemia Bates' Guide to Physical Examination and History Taking, 11e, 2012

Opening snap Mitral/tricuspid stenosis Audible sound due to restricted valve leaflet motion Bates' Guide to Physical Examination and History Taking, 11e, 2012

Harvey Mitral Area (apex) with BELL How many sounds do you hear? Three Which one is louder? First Is that normal at this location? Only if young (<30) #44  #46

Harvey “Ken---------------TUCK-------eh” “Lub----------------dup-----boom” “Rush--------------ing------in” #46

Harvey Mitral Area (apex) with BELL How many sounds do you hear? Three Which one is loudest? Second (S1) Is that third sound normal at this location? NO #44  #36

Harvey “Ten-nes----------see” or really "te NUS….see” “Huh-one--------two” “A STIFF---------heart” #36

Harvey Acute Anterior MI Mitral Area (apex) with BELL How many sounds do you hear? Four Which one is louder? S2—the ventricle has decreased ventricular contraction, so valves (M and T) closes slower and S1 is softer Is hearing four sounds normal at this location? No! #44  #40

Heart Murmurs Describing a murmur Timing: systole or diastole? Location: where is it loudest? Shape: crescendo, decrescendo, holosytolic? Intensity: grade? 1 (barely audible) to 6 (stethoscope off chest!) Pitch: high or low-pitched? Quality: harsh, blowing, rumbling, musical? Change with maneuvers? Bates' Guide to Physical Examination and History Taking, 11e, 2012

Systolic Murmur Review – last week Aortic Stenosis Mitral Regurgitation #13 #8 Location 2nd right intercostal Radiation Carotids, down sternal border, apex Intensity Can be Grade 4 or greater (thrill) Pitch Medium Quality Harsh; crescendo-decrescendo Maneuvers Sitting and leaning forward Associated findings Delayed carotid upstroke Mechanism Turbulence and decreased flow across aortic valve Location Apex Radiation Left axilla Intensity Similar Pitch Medium to high Quality Harsh; holosystolic Maneuvers Isometric handgrip Associated findings Apical S3, PMI changes Mechanism Failure of mitral valve to fully close in systole

With SEM, there is no murmur sound during Isovolumic contraction

Systolic Murmur Review Hypertrophic cardiomyopathy Congenital condition Massive ventricular hypertrophy (PMI) Rapid left ventricular ejection (carotid upstroke) Variable outflow obstruction (mid-systolic murmur) Increased with standing and Valsalva Risk for syncope and sudden cardiac death

HOCM MRI http://qjmed.oxfordjournals.org/content/106/9/873

Systolic Murmur Review Innocent Physiologic Location 2nd-4th left intercostal Radiation Little Intensity Grade 1-2, possibly 3 Pitch Soft to medium Quality Variable Maneuvers Decreased or absent with standing Associated findings None Mechanism Turbulent blood flow from strong ventricular ejection Location Similar Radiation Intensity Pitch Quality Maneuvers Associated findings Signs of associated condition Mechanism High flow in anemia, pregnancy, fever, hyperthyroidism

23 yr old athlete passed out while playing basketball Harvey 23 yr old athlete passed out while playing basketball #1

What do you hear at each area? Harvey What do you hear at each area? Aortic area Pulmonic area Tricuspid area Mitral area #1

Harvey Features? What kind of murmur? Where does it radiate? Harsh crescendo-decrescendo systolic ejection murmur Where does it radiate? Apex (never carotids) How can the murmur be changed? Position (standing vs squatting) Standing = LOUDER Squatting = SOFTER #1

18 yr old Healthy male College physical No Symptoms Harvey 18 yr old Healthy male College physical No Symptoms #22

What do you hear at each area? Harvey What do you hear at each area? Aortic area Pulmonic area Tricuspid area Mitral area #22

Harvey Features? What kind of murmur? Where does it radiate? Soft, crescendo-decrescendo systolic ejection murmur Where does it radiate? Usually nowhere How can the murmur be changed? Disappears with standing #22

Diastolic Murmurs Key features Key features 2nd-4th left intercostal Aortic regurgitation Mitral stenosis Key features 2nd-4th left intercostal High-pitched Blowing decrescendo Patient leaning forward Widened pulse pressure Bounding arterial pulses Key features Apex Low-pitched Decrescendo rumble Left lateral decubitus Accentuated S1 Opening snap Bates' Guide to Physical Examination and History Taking, 11e, 2012

Harvey 36 yr old male SOB BP 160/50 increased pulse pressure brisk peripheral pulses #17

What do you hear at each area? Harvey What do you hear at each area? Aortic area Pulmonic area Tricuspid area Mitral area #17

Harvey Features? What kind of murmur? Quality? Location/position? Decrescendo diastolic murmur Quality? High-pitched and blowing Location/position? Left sternal border, 3rd/4th ICS Patient sitting up and leaning forward Change in pulse? Widening pulse pressure (>40 mmHg) Bounding pulse with brisk upstroke and large amplitude #17

Dyspneic female in late 40’s Harvey Dyspneic female in late 40’s #5

What do you hear at each area? Harvey What do you hear at each area? Aortic area Pulmonic area Tricuspid area Mitral area #5

Harvey Features? What kind of murmur? Quality? Position? #4 Diastolic rumble Quality? Low-pitched (bell) Position? Left lateral decubitus #4

HI Michelena, M Enriquez-Sarano. N Engl J Med 2018;379:e9. https://www.nejm.org/doi/full/10.1056/NEJMicm1715353 Corrigan’s Pulse and Quincke’s Pulse HI Michelena, M Enriquez-Sarano. N Engl J Med 2018;379:e9.

TF Imran, EH Awtry. N Engl J Med 2018;379:e6. Severe Mitral Stenosis https://www.nejm.org/doi/full/10.1056/NEJMicm1715321 TF Imran, EH Awtry. N Engl J Med 2018;379:e6.

Systolic/Diastolic Murmurs Continuous Venous hum Turbulence in jugular veins Loudest in diastole Above medial third of clavicle, particularly on right Patent ductus arteriosus Open channel between aorta and pulmonary artery Machinery-like 2nd left intercostal Non-continuous Pericardial friction rub Inflammation of pericardial sac

Pericardial Friction Rub Timing: 3 components Atrial systole (late diastole) Ventricular systole (mid-to-late systole) Ventricular diastole (early-to-mid diastole) Location: variable; 3rd left interspace Radiation: little Intensity: variable Pitch: high Quality: scratchy Aids: patient leaning forward; “Hering” position

Harvey Healthy adult female #28

What do you hear at each area? Harvey What do you hear at each area? Aortic area Pulmonic area Tricuspid area Mitral area #28

Harvey Features? What kind of murmur? Quality? Radiation? #28 Continuous Quality? Loud, harsh, machinery-like Radiation? Clavicle #28

Harvey 38 yr old presenting to ED 1 day of sharp pleuritic chest pain relieved by leaning forward Preceded by 5 days of URI sxs, low grade fevers, and myalgias #30

What do you hear at each area? Harvey What do you hear at each area? Aortic area Pulmonic area Tricuspid area Mitral area #30

Accentuating Murmurs Standing/squatting Valsalva maneuver Isometric handgrip

Accentuating Murmurs Standing/squatting Standing Squatting Decreased venous return Decreased peripheral vascular resistance Decreased left ventricular volume Increased mitral valve prolapse with earlier systolic click Increased hypertrophic cardiomyopathy murmur Decreased innocent murmurs Squatting Increased venous return Increased peripheral vascular resistance Increased aortic stenosis murmur

Accentuating Murmurs Valsalva maneuver Forcible expiration against closed glottis “Bear down” Increased intrathoracic pressure Increased outflow tract obstruction Increased hypertrophic cardiomyopathy murmur

Accentuating Murmurs Isometric handgrip Increased arterial blood pressure Increased mitral regurgitation Increased aortic regurgitation Increased mitral stenosis

Summary

Third Heart Sound-Review LV S3 so low frequency may require work at to hear; RV S3 varies with respiration RV S3 (increases with inspiration) LV S3 S1 S2 S3 “KEN TUCK Y” LV/RV dysfunction High volume conditions Mitral/tricuspid regurgitation High-flow states Anemia Thyrotoxicosis Pregnancy Abnormal presence Timing: Following S2 (distant from down-stroke of carotid pulse) Changes: Age Normal presence <20 100% 20-29 67% 30-39 50% 40 0%

Fourth Heart Sound-Review Another low frequency, late diastolic sound during atrial contraction in a poorly compliant ventricle. Can be augmented with handgrip. RV S4 will vary with respiration S4 RV S4 (increases with inspiration) LV S4 S1 S2 “TENN ESSEE” Abnormal presence Timing: Immediately preceding S1 and upstroke of carotid pulse Hypertrophic ventricle Hypertension Aortic stenosis HOCM Ischemia Location: Apex at the xiphoid and left lower sternal border

Heart sounds by TIMING S2 Split S2 (0.04s) S4 (0.12-0.16s before S1) Opening Snap (0.04-0.12s) S3 (0.14-0.16s) S4 (0.12-0.16s before S1) S1 Split S1 (0.02-0.03s) Ejection click S4 S3 Midsystolic click(s) split split OS EC S2 S1

Accentuating Murmurs Standing/squatting Valsalva maneuver Mitral valve prolapse Hypertrophic cardiomyopathy Aortic stenosis Innocent murmurs Valsalva maneuver Isometric handgrip Mitral regurgitation Aortic regurgitation Mitral stenosis

Murmurs Aortic stenosis Mitral regurgitation Aortic regurgitation Systolic Diastolic Aortic stenosis Mitral regurgitation Aortic regurgitation Mitral stenosis

Pericardial Friction Rub Systolic (1) and diastolic (2) components Unique scratchy quality

Essential Auscultation http://hsd.luc.edu/simulation/aboutus/resources/ 54

Real heart sounds Blaufuss Multimedia: http://www.blaufuss.org/

Questions?