1. Cardiac Exam I
9 October 2018

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

3. 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

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

5. 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

6. 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

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

8. 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

9. 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 %
Left lateral decubitus 50%
Bates' Guide to Physical Examination and History Taking, 11e, 2012

10. Principles of Auscultation
The Instrument
Courtesy of

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

12. The Binaural Stethoscope (1851)

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

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

15. Principles of Auscultation
Correct Positioning Incorrect Positioning

16. Heart Sounds
Location
Frequency/pitch
Timing
Intensity/loudness

17. Heart Sounds
Location
Frequency/pitch
Timing
Intensity/loudness

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

19. Heart Sounds
Location
Frequency/pitch
Timing
Intensity/loudness

20. 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

21. Heart Sounds
Location
Frequency/pitch
Timing
Intensity/loudness

22. 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.

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

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

25. 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

26. 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

27. Heart Sounds
Location
Frequency/pitch
Timing
Intensity/loudness

28. 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

29. 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

30. Listening to HARVEY

31. 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

32. 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

33. 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

34. 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

35. 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

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

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

38. 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

39. 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

40. 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

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

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

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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

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

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

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

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

55. 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

56. 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
( 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

57. 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

58. Questions?

59. Bonus: Echocardiogram
Mild vs severe MR