Physical ExamPhysical ExamPart IIPart II

Kim A. Eagle, MDAlbion Walter Hewlett Professor

Director

Kim A. Eagle, MDKim A. Eagle, MDAlbion Walter Hewlett ProfessorAlbion Walter Hewlett Professor

DirectorDirector

University of MichiganUniversity of MichiganCardiovascular CenterCardiovascular Center

Physical Exam:Physical Exam:Part IIPart II

• Heart Sounds

• Heart Murmurs

HEART SOUNDSHEART SOUNDS

S1S1•• MITRAL + TRICUSPID CLOSURE (M1, T1)MITRAL + TRICUSPID CLOSURE (M1, T1)•• WIDE SPLITTING: RBBB, EBSTEINWIDE SPLITTING: RBBB, EBSTEIN’’SS

S2S2•• AORTIC + PULMONIC CLOSURE (A2, P2)AORTIC + PULMONIC CLOSURE (A2, P2)•• WIDE, PHYSIOLOGIC SPLITTING: RBBB, MRWIDE, PHYSIOLOGIC SPLITTING: RBBB, MR•• REVERSED (PARADOXICAL) SPLITTING: LBBB, REVERSED (PARADOXICAL) SPLITTING: LBBB,

RV PACING, SEVERE AS, HOCM, ISCHEMIARV PACING, SEVERE AS, HOCM, ISCHEMIA•• FIXED SPLITTING: ASDFIXED SPLITTING: ASD•• PULMONARY HTN: LOUD, SINGLE S2PULMONARY HTN: LOUD, SINGLE S2

S3 /S4 Gallop SoundsS3 /S4 Gallop Sounds

DIASTOLIC SOUNDSDIASTOLIC SOUNDS•• S3S3 ((““protoproto--diastolicdiastolic””))reliable indicator of LV reliable indicator of LV systolic dysfunction with systolic dysfunction with prognostic relevanceprognostic relevance

•• S4S4 ((““prepre--systolicsystolic””))associated with associated with ↑↑ LVEDPLVEDP

Drazner MH, et al. NEJM 2001;345:574

HEART SOUNDSHEART SOUNDS

Systolic ClicksSystolic Clicks•• EjectionEjection: Timing is co: Timing is co--incident withincident with

carotid upstrokecarotid upstrokeExamplesExamples: Ao/Pulm click (ES): Ao/Pulm click (ES)

•• NonNon--ejectionejection: Occurs after carotid up: Occurs after carotid up--strokestroke

ExampleExample: MVP: MVP

HEART SOUNDSHEART SOUNDS

Adventitious Diastolic SoundsAdventitious Diastolic Sounds•• Opening snap of mitral stenosisOpening snap of mitral stenosis

P2P2--OS interval inversely related to OS interval inversely related to LALA--LV pressure gradientLV pressure gradient

•• Pericardial knock Pericardial knock •• Tumor plop (myxoma)Tumor plop (myxoma)

HEART MURMURSHEART MURMURS

Systolic Heart MurmursSystolic Heart MurmursEarlyEarly: Acute MR, TR with normal PA: Acute MR, TR with normal PA

pressures pressures SettingsSettings:: Acute MI (Inf/Post > Ant)Acute MI (Inf/Post > Ant)

EndocarditisEndocarditisRuptured chordaeRuptured chordae

Acute vs. Chronic MRAcute vs. Chronic MR

HEART MURMURSHEART MURMURS

Systolic Heart MurmursSystolic Heart MurmursMidMid--systolic/Ejection: systolic/Ejection:

BenignBenignLeftLeft--sided: AS, HOCM, other sided: AS, HOCM, other RightRight--sided: PSsided: PS

LVOT OBSTRUCTIONLVOT OBSTRUCTION

FINDINGFINDING ASAS SASSAS DMSDMS HOCMHOCMPostPost--VPB PPVPB PP ↑↑ ↑↑ ↑↑ ↓↓ARAR ++ -- + + --S4S4 ++ -- -- ++Paradox S2Paradox S2 + + -- -- ++ECEC + + -- -- --LocationLocation 2RIS 1RIS 2RIS 4LIS2RIS 1RIS 2RIS 4LISCarotidCarotid ↓↓ R>L R>L ++ ↑↑

AS= aortic stenosis DMS= discrete, membranous ASSAS= supra-valvular AS HOCM= hypertrophic obstructive cardiomyopathyPP= pulse pressure VPB= ventricular premature beatEC= ejection click IS= interspace

HEART MURMURSHEART MURMURS

Caveats with Aortic StenosisCaveats with Aortic Stenosis•• Elderly: preserved carotidsElderly: preserved carotids•• Low output: Low output: ↓↓ intensityintensity•• Confusion with MR:Confusion with MR:

Gallarvardin effectGallarvardin effect↑↑ Intensity postIntensity post--VPBVPB

HEART MURMURSHEART MURMURS

Systolic Heart MurmursSystolic Heart Murmurs-- MidMid--late: late:

MVP (+/MVP (+/-- click)click)-- Differential radiation with leaflet prolapse Differential radiation with leaflet prolapse or flail:or flail:

posterior leaflet ante. radiationposterior leaflet ante. radiationanterior leafletanterior leaflet post. radiationpost. radiation

HEART MURMURSHEART MURMURS

Systolic Heart MurmursSystolic Heart MurmursHolosystolic/Plateau: Holosystolic/Plateau:

Chronic MRChronic MRChronic TRChronic TRVSDVSD

HEART MURMURSHEART MURMURS

DIASTOLIC MURMURSDIASTOLIC MURMURSEARLYEARLY

•• AR AR •• PR (GRAHAM STEELL)PR (GRAHAM STEELL)

MIDMID•• MS (ASSOCIATED FINDINGS)MS (ASSOCIATED FINDINGS)

•• TSTS•• FILLING COMPLEX (R or L) WITH LARGEFILLING COMPLEX (R or L) WITH LARGE

VOLUME LOAD DUE TO MR, TR, or ASDVOLUME LOAD DUE TO MR, TR, or ASD•• MYXOMAMYXOMA

HEART MURMURSHEART MURMURS

DIASTOLIC MURMURSDIASTOLIC MURMURSAortic Regurgitation (AR)Aortic Regurgitation (AR)

L > R sternal radiation with valve vs. root L > R sternal radiation with valve vs. root dis.dis.

Acute AR : soft, early diastolic murmurAcute AR : soft, early diastolic murmurChronic AR: classic high pitched, Chronic AR: classic high pitched,

decrescendodecrescendo

Pulmonic Regurgitation (PR)Pulmonic Regurgitation (PR)With severe PA HTN (loud P2, Graham With severe PA HTN (loud P2, Graham

Steell)Steell)After repair of TOF: low pitched, softAfter repair of TOF: low pitched, soft

HEART MURMURSHEART MURMURS

CONTINUOUS MURMURSCONTINUOUS MURMURS•• PDAPDA•• Ruptured Sinus of Valsalva aneurysmRuptured Sinus of Valsalva aneurysm•• AV fistula (Coronary, other)AV fistula (Coronary, other)•• Cervical venous hum, mammary souffleCervical venous hum, mammary souffle

QUESTIONQUESTION

For which of the following combination of findings For which of the following combination of findings would CT assessment of the ascending aorta be would CT assessment of the ascending aorta be indicated ?indicated ?

A.A. MidMid--systolic click at the apex with a midsystolic click at the apex with a mid--late grade late grade 2 systolic murmur.2 systolic murmur.

B.B. Late systolic click at the lower left sternal borderLate systolic click at the lower left sternal borderC.C. Early systolic click at the lower left sternal border Early systolic click at the lower left sternal border

with a grade 1 diastolic murmur along the left with a grade 1 diastolic murmur along the left sternal border.sternal border.

D.D. Early systolic click at the 2Early systolic click at the 2ndnd LICS with a grade 2 LICS with a grade 2 midmid--sytolic murmur. Click becomes softer on sytolic murmur. Click becomes softer on inspiration.inspiration.

Dynamic AuscultationDynamic Auscultation

RespirationRespiration↑↑ RR--sided murmurssided murmurs↓↓ LL--sided murmurssided murmurs

ExampleExample: TR (Carvalho: TR (Carvalho’’s sign)s sign)ExceptionException: pulmonic valve click: pulmonic valve click

Dynamic AuscultationDynamic Auscultation

Valsalva ManueverValsalva Manuever↓↓ venous return, venous return, ↓↓ preload, preload, ↑↑ afterloadafterload

ExamplesExamplesHOCM: HOCM: ↑↑ obstruction, obstruction, ↑↑ murmurmurmur

AS: AS: ↓↓ preload, preload, ↓↓ murmurmurmurMVP: MVP: ↓↓ preload, preload, ↑↑ murmurmurmur

Dynamic AuscultationDynamic Auscultation

Standing/SquattingStanding/SquattingStanding: rapid Standing: rapid ↓↓ preload/afterloadpreload/afterloadSquatting: rapid Squatting: rapid ↑↑ preload/afterloadpreload/afterload

ExampleExampleHOCM: HOCM: standstand: : ↑↑ murmurmurmur

squatsquat: : ↓↓ murmurmurmur

Dynamic AuscultationDynamic Auscultation

Standing/SquattingStanding/SquattingStanding: rapid Standing: rapid ↓↓ preload/afterloadpreload/afterloadSquatting: rapid Squatting: rapid ↑↑ preload/afterloadpreload/afterload

ExampleExampleMVP: MVP: standstand: click/murmur closer: click/murmur closer

to S1, to S1, ↑↑ murmurmurmursquatsquat: click/murmur away : click/murmur away from S1, from S1, ↓↓ murmurmurmur

Dynamic AuscultationDynamic AuscultationMVPMVP

Dynamic AuscultationDynamic Auscultation

Hand Grip/4 Extremity BP CuffHand Grip/4 Extremity BP Cuff↑↑ afterloadafterload

ExamplesExamplesMR: MR: ↑↑ murmurmurmurVSD: VSD: ↑↑ murmurmurmur

QUESTION QUESTION

Which of the following murmurs decreases Which of the following murmurs decreases in intensity during the Valsalva maneuver?in intensity during the Valsalva maneuver?

A. Chronic mitral regurgitationA. Chronic mitral regurgitationB. Aortic stenosisB. Aortic stenosisC. HOCMC. HOCMD. MVPD. MVP