Cardiovascular Physical Exam Pearls

1. Cardiovascular Physical Exam Pearls Daniel J. O’Rourke, MD Cardiology Symposium December 2004

2. Valvular Abnormality • Cardiovascular Exam • JVP – pressure & pulsations • Carotid Pulse – rate, rhythm, rate of rise, volume, compliance • Inspection • Palpation – LV apical impulse, PMI • Heart Sounds – intensity & 2 components to S1 and S2. Gallops • Murmur

3. DDX of a “2 Component” S1 • S4-S1 (noncompliant LV) • S1-Ejection sound (valvular or aortic root dilatation) • S1-Click (MVP) • M1-T1 splitting (normal or pathologic - RBBB)

4. DDX of a “2 Component” S2 • Splitting of S2 (normal, narrow, wide, paradoxical) • S2-S3 (physiologic vs. pathologic – normal LV, dilated LV) • S2-opening snap (mitral stenosis) • S2-pericardial knock (constrictive pericarditis) • S2-tumor plop (atrial myxoma)

5. Mid Systolic (SEM) 1. Physiologic or flow murmur 2. Aortic stenosis 3. HOCM Late Systolic 1. Papillary muscle dysfxn Holosystolic 1. MR 2. TR 3. VSD Early Diastolic 1. Aortic regurgitation 2. Pulmonic regurgitation Mid & Late Diastolic 1. Mitral stenosis 2. Tricuspid stenosis Overview of Murmurs

6. Evaluation of Murmurs • Timing - Systolic vs. Diastolic • Intensity - Grade I-VI • Characteristics Quality (blowing, harsh, musical) Pitch (high or low) • Duration • Shape of murmur • Location • Radiation

7. Clinical ScenarioIn-hospital patient develops a new murmur • Clinical question: Endocarditis? • Murmurs associated with left-sided endocarditis – AR, MR • Tachycardia • Soft S1 – severe AR or moderate to severe MR • Pulmonary edema • Diastolic murmur (AR), systolic murmur (MR) • Classic findings of chronic AR are rarely present • Features of a physiologic or flow murmur

8. Physiologic Murmur(Flow, Functional) • Common in hyperkinetic states • Caused by rapid ejection of blood • Starts shortly after S1 and peaks by mid systole • Intensity related to velocity of blood flow - Never > Grade III • Absence of concomitant cardiac pathology

9. Pathologic vs. Nonpathologic Murmurs Always pathologic if: • Diastolic murmur • Holosystolic or late systolic murmur • Continuous murmur • Grade 4-6 murmurs • Concomitant cardiac symptoms or exam findings

10. Clinical ScenarioKnown AS – when do I need to order a follow-up echo? • History – angina, syncope (lightheadedness), heart failure (dyspnea) • Physical exam findings • Mean annual progression • AVA decreases by ~0.1 cm2 • Mean gradient increases by ~10 mmHg AVAMean Gradient Mild >1.5 cm2 <25 mmHg Moderate 1.0-1.4 25-49 mmHg Severe <1.0 >50 mmHg

11. Aortic Stenosis Three major causes • Congenital, Rheumatic, and Degenerative (calcific) Classic murmur • Harsh, crescendo-decrescendo SEM at the base • Radiates to the carotids and/or apex (Gallavardin) Clues to assessing severity: • Carotid upstroke • Duration of the murmur • Splitting of S2

12. Splitting of S2 Physiologic --> Mild Single --> Mod/Severe Paradoxical --> Severe Murmur Peak Early-mid --> Mild Mid-late --> Moderate Late --> Severe Assessing AS Severity by Exam Sustained LV apical impulse, S4 gallop – Moderate to severe Delayed, diminished carotid upstroke - Severe

13. Obtaining an Echocardiogram: Aortic Stenosis IndicationsClass • Diagnosis and severity of AS I • Assessment of LV size, function, and/or hemodynamics I • Reevaluation of patients with known AS with I changing symptoms or signs • Reassessment of asymptomatic patients with severe AS I JACC 1998;32:1486-1588.

14. Obtaining an Echocardiogram: Aortic Stenosis IndicationsClass • Reassessment of asymptomatic patients with IIa mild to moderate AS and LV dysfunction or hypertrophy • Reassessment of asymptomatic patients with stable III exam findings and normal LV size and function JACC 1998;32:1486-1588.

15. Frequency of Surveillance Echo Asymptomatic, clinically stable patients • Mild AS Every 5 years • Moderate AS Every 2 years • Severe AS Annually

16. Chronic Mitral Regurgitation Pathophysiologic mechanisms • Mitral valve leaflets • Papillary muscles • Chordae tendinae • Annulus Classic murmur • High pitched, blowing, holosystolic murmur at the apex • Radiates to the axilla or left sternal border

17. Mild MR Normal carotid upstroke Normal LV apical impulse Heart Sounds Normal intensity of S1 Grade 1-2 murmur Moderate-Severe MR Carotid pulse - Brisk upstroke Hyperdynamic, displaced LV apical impulse Heart Sounds Soft S1 S2 widely split S3 gallop Assessing MR Severity by Exam

18. Obtaining a TTE: Chronic Mitral Regurgitation IndicationsClass • Baseline evaluation to quantify severity of MR I and assess LV function • Determine the mechanism of MR I • Annual or semi-annual surveillance of LV function I in asymptomatic severe MR • To establish cardiac status after a change in sxs I • Evaluation post MVR to establish baseline status I • Routine f/u evaluation of mild MR with normal III LV size and function JACC 1998;32:1486-1588.

19. Summary • The cardiovascular exam remains the most widely used method to screen for heart disease. • Echocardiography is an important noninvasive method for assessing the significance of cardiac murmurs and to define cardiac structure and function.