Cardiac Exam I 9 October 2018

Goals Review steps of cardiac examination Connect cardiac physiology (and electrophysiology) to exam findings Augment Harvey experience

Heart I Objectives Identify and describe PMI Find systole on auscultation Understand variations in S1 Understand variations in S2 Distinguish normal from abnormal splitting of S2 Differentiate early ejection sound from systolic click Contrast midsystolic and pansystolic murmurs

Identify the following heart sounds Split S1 S2 Split S2 (4 types) Ejection click Midsystolic click Aortic stenosis murmur Mitral regurgitation murmur

The Cardiac Examination Position General: supine with head at 30 degrees PMI/S3/S4/MS: left lateral decubitus AR/tricuspid murmurs/rubs: leaning forward Quiet room, exhale fully, hold breath Bates' Guide to Physical Examination and History Taking, 11e, 2012

The Cardiac Examination Retrosternal air Retrosternal air Lat CXR with COPD with air trapping, flat diaphragm, and increased retrosternal air Normal lateral CXR Lateral CXR with minimal retrosternal air and enlarged cardiac silhouette

The Cardiac Examination Inspection Deformity Lifts/heaves Apical impulse Bates' Guide to Physical Examination and History Taking, 11e, 2012

The Cardiac Examination Percussion? Palpation Lifts/heaves Palm +/- fingertips Thrills Ball of hand S1/S2 Right hand: chest wall Left index/middle fingers: right carotid artery Bates' Guide to Physical Examination and History Taking, 11e, 2012

The Cardiac Examination Point of maximal impulse (PMI) Left ventricular area Consider left lateral decubitus position Exhale and hold (patient, not you) Descriptors: Location Diameter Amplitude Duration Supine 25-40% Left lateral decubitus 50% Bates' Guide to Physical Examination and History Taking, 11e, 2012

Principles of Auscultation The Instrument Courtesy of

RenÉ-ThÉophile-hyacinthe Laennec (1816) Memorial plate of Laennec, Hopital Necker, Rue de Sevres, Paris, France

The Binaural Stethoscope (1851)

Principles of Auscultation Acoustics Audible sound 20-20,000 Hz High-pitched ≥ 300 Hz Medium-pitched 100-250 Hz Low-pitched rumbling 60-100 Hz Environment matters Weakest sound heard 0 dB Whisper, quiet library 30 dB Normal conversation (3-5') 60-70 dB Emergency room average >70 dB Intensive care units 65-85 dB City traffic (inside car) 85 dB Truck traffic 90 dB

Principles of Auscultation Acoustics Audible sound 20-20,000 Hz High-pitched ≥ 300 Hz Medium-pitched 100-250 Hz Low-pitched rumbling 60-100 Hz Environment matters Weakest sound heard 0 dB Whisper, quiet library 30 dB Normal conversation (3-5') 60-70 dB Emergency room average >70 dB Intensive care units 65-85 dB City traffic (inside car) 85 dB Truck traffic 90 dB

Principles of Auscultation Correct Positioning Incorrect Positioning

Heart Sounds Location Frequency/pitch Timing Intensity/loudness

Heart Sounds Location Frequency/pitch Timing Intensity/loudness

Location Bates' Guide to Physical Examination and History Taking, 11e, 2012

Heart Sounds Location Frequency/pitch Timing Intensity/loudness

Frequency/Pitch Diaphragm Bell (with light pressure) High pitched sounds S1, S2, midsystolic click Aortic regurgitation, mitral regurgitation Bell (with light pressure) Low pitched sounds S3, S4 Mitral stenosis Bates' Guide to Physical Examination and History Taking, 11e, 2012

Heart Sounds Location Frequency/pitch Timing Intensity/loudness

The Cardiac Cycle [S2] [S1] 1 Late diastole: both sets of chambers are relaxed and ventricles fill passively. START Isovolumic ventricular relaxation: as ventricles relax, pressure in ventricles falls, blood flows back into cups of semilunar valves and snaps them closed. 2 Atrial systole: atrial contraction forces a small amount of additional blood into ventricles. [S2] 5 [S1] Ventricular ejection: as ventricular pressure rises and exceeds pressure in the arteries, the semilunar valves open and blood is ejected. 4 3 Isovolumic ventricular contraction: first phase of ventricular contraction pushes AV valves closed but does not create enough pressure to open semilunar valves.

The Cardiac Cycle Bates' Guide to Physical Examination and History Taking, 11e, 2012

Heart Sounds – The Basics https://s3- amazonaws- com.archer.luhs.or g/wk6- healthlibrary/lill5/ Lilly_heartSound_F inal.html

When is systole? After diastole Before diastole Use additional senses: Auscultate over the heart Palpate the carotid artery S1 immediately precedes carotid upstroke S2 immediately follows carotid downstroke Bates' Guide to Physical Examination and History Taking, 11e, 2012

Copyright © Wolters Kluwer From: The Cardiovascular System Bates' Guide to Physical Examination and History Taking, 11e, 2012 Legend: Imagine carotid pulsation by palpation to follow arterial pressure changes. Note relatively greater duration of diastole. Date of download: 10/20/2014 Copyright © Wolters Kluwer

Heart Sounds Location Frequency/pitch Timing Intensity/loudness

Cardiac Auscultation Which is higher pressure side, right or left? Higher pressure = LOUDER Sounds from left side are LOUDER Which occurs first, right or left sided sounds? Aortic before pulmonic Mitral before tricuspid What causes S1 and S2? Valve closure First Aid for the Boards. 2013: 264

Factors Affecting Sound Intensity Heart rate (arrhythmias) Timing between atrial and ventricular contraction (heart block) Cardiac output Leaflet excursion Leaflet stiffness Opening and closing pressures

Listening to HARVEY

Hold Up Your Fingers Nod Your Head Harvey Aortic Area (right 2nd ICS) How many sounds do you hear? Two Which one is louder? Second Is that normal at this location? Yes, S2 is louder than S1 at aortic area #44

Harvey Hold Up Your Fingers Nod Your Head Pulmonic Area (left 2nd ICS) How many sounds do you hear? Three (Inspiration) vs two (Expiration) Which one is louder? S2>S1, A2>P2 Is that normal at this location? Yes #44 vs #41

Harvey Hold Up Your Fingers Nod Your Head Tricuspid Area (LLSB) How many sounds do you hear? Three Which one is louder? First Is that normal at this location? Yes #44

Harvey Hold Up Your Fingers Nod Your Head Mitral Area How many sounds do you hear? Two Which one is louder? First Is that normal at this location? Yes #44

Heart Sounds – S1 Apex Tachycardia Short PR interval Accentuated Diminished Apex Tachycardia Short PR interval High cardiac output states Mitral stenosis Base First degree heart block Mitral regurgitation (immobile valve) Decreased contractility of ventricle

Heart Sounds – S1 Splitting of S1 Normal Abnormal Left lower sternal border Abnormal Right bundle branch block Premature ventricular contractions

Heart Sounds - S2 Systemic hypertension Dilated aortic root Accentuated A2 Diminished A2 Systemic hypertension Dilated aortic root Aortic stenosis

Heart Sounds - S2 Pulmonary hypertension Dilated pulmonary artery Accentuated P2 Diminished P2 Pulmonary hypertension Dilated pulmonary artery Atrial septal defect Pulmonic stenosis Increased AP diameter

Heart Sounds – S2 Splitting of S2 Physiologic Pathologic Increased on inspiration Less on expiration Pathologic Fixed splitting Paradoxical splitting Wide splitting Bates' Guide to Physical Examination and History Taking, 11e, 2012

S2 - Pathologic Splitting Fixed splitting (A2 stays before P2) Atrial septal defect Right ventricular failure Paradoxical splitting (P2 before A2) Left bundle branch block Delayed systole in left ventricle Wide splitting (increases with inspiration) Right bundle branch block Pulmonic stenosis

Harvey Examples of Splitting --fixed Pulmonic Area (left 2nd ICS) Note the kind of splitting you hear: Harvey #23

Harvey Examples of Splitting--Paradoxical Pulmonic Area (left 2nd ICS) Note the kind of splitting you hear: Harvey INSPIRATION #48

Examples of Splitting--Wide Pulmonic Area (left 2nd ICS) Note the kind of splitting you hear: Harvey #40

Extra Heart Sounds in Systole Early Ejection Sound (Ej or ES) Systolic Click (C1) Aortic Apex Dilated aorta Aortic stenosis Bicuspid aortic valve Pulmonic 2nd/3rd left intercostal Pulmonary artery dilation Pulmonic stenosis Pulmonary hypertension Mitral valve prolapse Systolic ballooning Mid- or late-systolic Apex High-pitched (diaphragm) +/- mitral regurgitation Delayed by squatting 2-3% of general population

Harvey Ejection sound Mitral Area (apex) with DIAPHRAGM How many sounds do you hear? Three Which one is louder? First and second are about equal Is that normal at this location? No #33 mitral area

Harvey Mitral valve prolapse Systolic click Tricuspid Area (LLSB) with DIAPHRAGM How many sounds do you hear? Three Note that the sound is MID systolic (a “mid-systolic click”) #10 46

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

Pansystolic (holosystolic) Systolic Murmurs Midsystolic Pansystolic (holosystolic) Innocent/physiologic Aortic stenosis Hypertrophic cardiomyopathy Pulmonic stenosis Mitral regurgitation Tricuspid regurgitation Ventricular septal defect Bates' Guide to Physical Examination and History Taking, 11e, 2012

Pansystolic (holosystolic) Systolic Murmurs Midsystolic Pansystolic (holosystolic) Innocent/physiologic Aortic stenosis Hypertrophic cardiomyopathy Pulmonic stenosis Mitral regurgitation Tricuspid regurgitation Ventricular septal defect Bates' Guide to Physical Examination and History Taking, 11e, 2012

Harvey Systolic ejection murmur How many sounds do you hear? Four plus a murmur Which one is louder? Second and third are about equal What is the timing of the murmur? Systole What is the “shape”? Diamond Do you hear A2? Yes Does it radiate? Yes Pulse change? Yes #13 Apex with bell

Harvey 50 year old woman history of Childhood rheumatic fever Presenting for routine exam Asymptomatic

What Do You Hear at Each Area? Harvey Aortic area Pulmonic area Tricuspid area Mitral area #8

Mitral Regurgitation Holosystolic murmur= plateau = pansystolic Radiates to axilla S1 and S2 difficult to hear as distinct, isolated sounds Mitral area S1 S2

Summary PMI – find it (50%) and describe it Auscultation – consider the instrument and the environment Objective #1 – identify systole

First Heart Sound-Review Source: Closure of mitral and tricuspid valves Timing: Immediately preceding up- stroke of carotid pulse Sound: Lower frequency than S2, heard with bell or diaphragm T1 M1 S1 S2 Louder Softer Wide split Tachycardia Short PR interval High cardiac output states Mitral stenosis First degree heart block Mitral regurgitation Decreased contactility of ventricle Right bundle branch block Premature ventricular contractions

Second Heart Sound-Review Louder aortic sound (A2) precedes the pulmonic (P2) that normally widens with inspiration. S1 S2 Source: Closure of aortic and pulmonic valves Timing: Immediately following down- stroke of carotid pulse A2 P2 Sound: Medium pitch (70 - 150 Hz), heard best with diaphragm Louder Softer A2 P2 A2 P2 Pulmonary hypertension Dilated pulmonary artery Atrial septal defect Systemic hypertension Dilated aortic root Aortic stenosis Pulmonary stenosis COPD Wide split (A2 - P2) Reverse split (P2 - A2) Fixed split (A2 - P2) Right bundle branch block Pulmonic stenosis Left bundle branch block Delayed left ventricular contraction Atrial septal defect Right ventricular failure

Summary (continued) Early ejection sound – usually aortic valve disease Systolic click – usually mitral valve prolapse Systolic murmurs – can be mid-systolic or holosystolic Bates' Guide to Physical Examination and History Taking, 11e, 2012

Questions?

Bonus: Echocardiogram Mild vs severe MR