Cardiovascular Physical exam review

Dr. Pattarapong Makarawate, MD

CARDIAC TAMPONADE

CONGESTIVE HEART FAILURE

AORTIC REGURGITATION

AORTIC REGURGITATION

AORTIC STENOSIS

ABNORMALITIES OF THE ARTERIAL PULSE

JVP Inspection

Normal JVP Waveform

l Consists of 3 positive waves l a,c & v

l And 3 descents l x, x'(x prime)

and y

THE CENTRAL VENOUS PRESSURE

A WAVE- ATRIAL CONTRACTON C WAVE- BULGING OF TRICUSPID VALVE X DESCENT- ATRIAL RELAXATION V WAVE-CLOSURE OF TRICUSPID VALVE WITH ATRIAL DISTENSION Y DESCENT- OPENING OF THE TRICUSPID VALVE

JAMA 1996;275:630-634

l  a wave - atrial systole l  x descent – onset of

atrial relaxation l  c wave - small positive

notch in the 'x' descent due to bulging of the AV ring into the atria in ventricular contraction.

l  x' (prime) descent !!! l  occurs during systole due

to RV contraction pulling down the TV valve ring “descent of the base”

l  a measure of RV contractility

l  v wave - after the x' descent - slow positive wave due to right atrial filling from venous return

l  y descent - rapid emptying of the RA into RV due to TV opening

Normal JVP Waveform

JVP- HJR & Kussmaul’s sign

l  Hepato-jugular reflux (various definitions) l  sustained rise 1 cm

for 30 sec. l  ↑ venous tone &

SVR l  ↓ RV compliance

l  Positive HJR correlates with LVEDP > 15

l  JVP normally falls with inspiration

l  Kussmaul’s sign l  inspiratory ↑ in JVP l  constriction l  rarely tamponade l  RV infarction

Specific JVP patterns Condition Pattern

Normal waveform X' deeper than Y

Post CABG X' shallower, now = Y

Atrial fibrillation CV wave

Tricuspid regurgitation CV wave

Complete heart block Irregular cannon A waves

Tamponade ↑ JVP brisk X' > Y

Constriction ↑ JVP brisk X' & Y descents X' less exaggerated than Y

RV infarction ↑ JVP –low amplitude

CANNON A WAVE AHA EXAMINATION OF THE HEART PART 2

CLASS NOTES

THE BASIC HEART SOUNDS

BRAUNWALD E.HEART DISEASE 1994 ;29

AHA EXAMINATION OF THE HEART PART 4

NORMAL AND ABNORMAL 2ND HEART SOUNDS

AHA EXAMINATION OF THE HEART PART 4

THE 3RD HEART SOUND

l  VENTRICULAR ORIGIN - FROM RAPID DIASTOLIC FILLING

l  EARLY DIASTOLE l  BELL l  > 40 YO ABNORMAL l  < 40 YO MAY BE NORMAL l  CONGESTIVE HEART FAILURE OR

VALVULAR DISEASE

l  ATRIAL ORIGIN - RAPID DIASTOLIC FILLING

l  LATE DIASTOLE l  HYPERTROPHY OR FIBROTIC VENTRICLE l  BEL l  REQUIRES ATRIAL KICK DISAPPEARS IN

PATIENTS WITH A FIB l  AORTIC STENOSIS, HYPERTROPHIC

CARDIOMYOPATHY, HYPERTENSION

THE 4TH HEART SOUND

AHA EXAMINATION OF THE HEART PART 4

Diastolic extra sounds

l  1. Opening snap ( OS ) l  2. Pericardial knocks l  3. Tumor plop l  4. Third heart sound ( S3 ) l  5. Fourth heart sound ( S 4 ) l  - decrease LV compliance : LVH

( HT,AS,HOCM ),ischemia l  - RV S4 gallop: increase with inspiration: PHT,

PS , Ebstein anomaly

MURMURS - INTENSITY

l  GRADE I - HEARD, TUNE IN l  GRADE II – FAINT l  GRADE III – BETWEEN 3 AND 4 l  GRADE IV – ASSOCIATED WITH A THRILL l  GRADE V – HEARD IF JUST THE RIM OF

THE STETHOSCOPE TOUCHES THE CHEST

l  GRADE VI – HEARD WITHOUT TOUCHING THE CHEST

FREEMAN AND LEVINE ANN INT MED 6:1371;1993

SYSTOLIC MURMURS JAMA 1997;277:564-571

LOCATION OF SYSTOLIC MURMURS

JAMA 1997;277:564-571

Systolic Murmurs by Position

l RUSB - AS

l LLSB – TR, VSD, HCM

l APEX - MR

Diastolic Murmurs by Position

l LUSB - PR

l LLSB - TS l APEX - MS

l 3RD ICS, LSB - AR

Aortic Valve stenosis

PE in severe AS

l S 4 ( especially in < 40 years ) l SEM : long and peak in midsystole + at

least grade > 4/6 ( except in poor LV ) l  A2 : decrease absent l  Paradoxical split S 2 ( prolong LV

ejection time ).

HOCM

l Bisferiens pulse l  double apical impulse ( palpable

presystolic wave at apex and double systolic lift )

l Prominent S4, paradoxical split of S2

HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY (HOCM)

PHYSICAL FINDINGS

MURMUR MAY BE HARSH

LLSB

MANEUVERS

SQUATTING

STANDING

DM 1994;52-112

DDx HOCM vs AS

l HOCM ; location at LLSB > AVA l Carotid pulse : bisferiens > pulsus

parvus et tardus l LV impulse : double apical impulse l  Valsava ( strain phase ) increase

murmur. l  Squatting decrease murmur.

Aortic Insufficiency

Mitral stenosis : Investigation

•  EKG •  CXR •  Echo

OS

Mitral stenosis : Auscultation

MVA

Mitral Valve Prolapse

Effect of special maeuvers

l Suspected MVP: standing make the click and systolic murmur earlier.

l Suspected HOCM: hand grip and squating make intensity of murmur decrease. : valsava and standing make intensity of murmur increase.

Short cases

Most common case l  Mitral stenosis + TR l  Mitral regurgitation + MVP l  Aortic stenosis l  Aortic regurgitation l  Pulmonic stenosis l  Continuous murmur l  PDA + PHT l  Coronary AV fistula l  Rupture sinus of valsava to RV or RA

Short cases

Most common case l  ASD with PHT l  VSD l  Atrial fibrillation l  Bradycardia Complete AV block l  Hyperthyroidism l  Marfan syndrome with AR+MR l  Dextrocardia with ?

Short cases

l Uncommon cases l  Tetralogy of fallot l  Congenital heart disease with reverse

shunt l  Hypertrophic cardiomyopathty

HOCM l  Constrictive pericarditis l  Prosthetic heart valve dysfunction l  Pulmonic regurgitation in PHT l  Pericarditis with pericardial rub

Technique

l Use time efficiency l Don’t miss some clues l Repeated cases? l Neck vein clues. l Peripheral pulse deficit. l Wide pulse pressure. l Good describe and complete answer.

Long cases

Common cases l  Multiple valves problem l  Hyperthyroidism l  Tetralogy of fallot l  Hypertrophic cardiomyopathty HOCM l  Dilated cardiomyopathy caused? l  Restrictive cardiomyopahy in

amyloidosis, unknown caused

Long cases

Common cases l  Constrictive pericarditis from TB l  Secondary hypertension, renal artery

stenosis l  Infective endocarditis (subacute IE) and

complication l  Reverse shunt congenital heart disease l  Prosthetic heart valve malfunction l  Primary pulmonary hypertension and

secondary l  Coarctation of aorta

Long cases

Common cases l Takayasu disease l Marfan syndrome l Acute coronary syndrome with

complication VSD, MR l Sudden cardiac arrest and arrhythmia l Congestive heart failure l Dextrocardia

Long cases

Uncommon cases l  Chronic Aortic dissection l  Chronic pulmonary embolism l  Coarctation of aorta l  Aortic aneurysm l  Ebstein’s anomaly with WPW l  Vitamin B1 deficiency: cardiac beriberi l  Transposition of great vessel l  Pericarditis and pericardial effusion

Cyanotic heart disease

Common l  Tetralogy of fallot l  Eisenmenger’ syndrome l  Pulmonary atresia with VSD l  Pulmonic stenosis with right to left

shunt

Tips

l Graham steel murmur = Pulmonic regur. due to PHT.

l Austin Flint murmur = MS murmur caused by AR jet.

l Pulsus paradoxus in cardiac temponade

Tips

PE in ASD

l Pulse normal, sometimes small l Normal JVP ( v wave in severe TR ) l RV heave, normal apex beat l Wide fixed split S2, increase P 2 if PHT l SEM at PVA l  TR if PHT

Tips VSD

Harsh HSM grade 3-4/6. Maximal at the 3rd -4th ICS LPSB.

Apical diastolic rumble (increase flow through MV) S3 at apex

PE in VSD

l 1. Small VSD l  - normal pulse and JVP. l  - thrill at LLSB, no LV/RV heave. l  - normal or wide split S2. l  - PSM at LLSB ( radiate to right of

sternum/apex but not to axilla ).

PE in VAS

l 2. large shunt , normal PA pressure l  murmur/thrill same l  LV heave ( volume overload pattern ) l  S3 and apical mid diastolic murmur

( from increase flow ). l  if moderate PHT: RV heave+palpable

P2,wide split S2

VSD with Eisenmenger

l Cyanosis, RV heave(pressure overload ) l  no thrill, palpable P2 l  early diastolic rumble of PR.

PDA

Diastolic murmur disappear + loud P2 in moderate PHT

Continuous murmur grade 1–2, peaking in late systole, and best heard in the 1st – 2nd ICS-LPSB

LV volume overload (apical displacement + S3)

Wide pulse pressure

Continuous murmur

l  1. R/O to-and-fro murmur l  2. PDA : left infraclavicular / PVA , in PHT

decrease diastolic murmur , in severe PHT = PR murmur.

l  3. Ruptured sinus of valsava ( Rt/non cusp to RA/RV ) : lower sternal boarder.

l  4. Coronary AV fistula : coronary artery to RA/RV : lower sternal boarder.

COARCTATION OF AORTA

CLINICAL MANIFESTATION

Crescendo-decrescendo systolic murmur throughout chest wall from collateral a.

Radial-femoral pulse delay unless significant AR

LVH

Interscapular systolic murmur from the coarctation site

Differential SBP > 10 mm Hg (brachial >popliteal a.)

RIGHT VENTRICULAR OUTFLOW TRACT OBSTRUCTION

CLINICAL MANIFESTATION

Systolic ejection click (decreases on inspiration)

Unusual in dysplastic PS or subvalvar or supravalvar RVOTO

Prominent JVP, RV lift, a thrill in the 2nd LICS

SEM • Valvular stenosis in 2nd LICS • Subvalvular stenosis at 3rd -5th LICS • Supravalvular stenosis: wide distribution

Normal S1, a split S2 with a diminished P2 (except supravalvular)

TETRALOGY OF FALLOT

Most common form of cyanotic CHD after 1 year (10%) of CHD

CLINICAL MANIFESTATION

Continuous murmurs: to assess shunt patency

Low-pitched DBM from PR at LPSB. RVH SEM from RVOTO

Soft and delayed P2 High-pitched DBM - AR, HSM - VSD patch leak.

An ejection sound from aortic dilation

EBSTEIN ANOMALY

ANATOMY

l  Apical displacement of the septal, posterior, or (rarely) anterior leaflet of the TV

l  Atrialization (functioning as an atrial chamber) of the inflow tract of RV and small functional RV

l  TR (or in exceptional TS) l  Associated anomalies include

l  PFO or ASD (50%) l  Accessory pathways

(25%) l  RVOTO, VSD,

coarctation of the aorta, PDA, or mitral valve disease

CLINICAL MANIFESTATION

Unimpressive JVP (large and compliant RA and atrialized RV)

SEM from TR Right side S3

Widely split S1 with a loud tricuspid component (the “sail sound”) Widely split S2 from RBBB

Cyanosis R-L shunt

DIAGNOSTIC TESTING

Electrocardiogram. l  Low voltage: typical l  Peaked P waves in lead

II and V1 l  Prolonged PR interval l  Short PR interval and a

delta wave (WPW type B )

l  An rsr´ pattern = RV conduction delay is typically seen in lead V1

l  AF/AFL are common l  ECG may be normal

DIAGNOSTIC TESTING CHEST RADIOGRAPHY

“water bottle” appearance l  A rightward convexity

l  Enlarged RA and atrialized RV

l  Leftward convexity l  Dilated infundibulum

l  Cardiomegaly, highly variable in degree

l  The pulmonary vasculature is usually normal to reduced