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

2. Valvular Abnormality Cardiovascular ExamCardiovascular Exam JVP – pressure & pulsationsJVP – pressure & pulsations Carotid Pulse – rate, rhythm, rate of rise, volume, complianceCarotid Pulse – rate, rhythm, rate of rise, volume, compliance InspectionInspection Palpation – LV apical impulse, PMIPalpation – LV apical impulse, PMI Heart Sounds – intensity & 2 components to S 1 and S 2. GallopsHeart Sounds – intensity & 2 components to S 1 and S 2. Gallops MurmurMurmur

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

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

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

6. Evaluation of Murmurs Timing - Systolic vs. DiastolicTiming - Systolic vs. Diastolic Intensity - Grade I-VIIntensity - Grade I-VI CharacteristicsCharacteristics Quality (blowing, harsh, musical) Pitch (high or low) DurationDuration Shape of murmurShape of murmur LocationLocation RadiationRadiation

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

8. Physiologic Murmur (Flow, Functional) Common in hyperkinetic states Common in hyperkinetic states Caused by rapid ejection of blood Caused by rapid ejection of blood Starts shortly after S 1 and peaks by mid systole Starts shortly after S 1 and peaks by mid systole Intensity related to velocity of blood flow - Never > Grade III Intensity related to velocity of blood flow - Never > Grade III Absence of concomitant cardiac pathology Absence of concomitant cardiac pathology

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

10. Clinical Scenario Known AS – when do I need to order a follow-up echo? History – angina, syncope (lightheadedness), heart failure (dyspnea)History – angina, syncope (lightheadedness), heart failure (dyspnea) Physical exam findingsPhysical exam findings Mean annual progressionMean annual progression AVA decreases by ~0.1 cm 2AVA decreases by ~0.1 cm 2 Mean gradient increases by ~10 mmHgMean gradient increases by ~10 mmHg AVAMean Gradient Mild >1.5 cm 2 1.5 cm 2 <25 mmHg Moderate 1.0-1.4 25-49 mmHg Severe 50 mmHg

11. Aortic Stenosis Three major causes Congenital, Rheumatic, and Degenerative (calcific)Congenital, Rheumatic, and Degenerative (calcific) Classic murmur Harsh, crescendo-decrescendo SEM at the baseHarsh, crescendo-decrescendo SEM at the base Radiates to the carotids and/or apex (Gallavardin)Radiates to the carotids and/or apex (Gallavardin) Clues to assessing severity: Carotid upstrokeCarotid upstroke Duration of the murmurDuration of the murmur Splitting of S 2Splitting of S 2

12. Assessing AS Severity by Exam Splitting of S 2 Physiologic --> Mild Physiologic --> Mild Single --> Mod/Severe Single --> Mod/Severe Paradoxical --> Severe Paradoxical --> Severe Murmur Peak Early-mid --> Mild Early-mid --> Mild Mid-late --> Moderate Mid-late --> Moderate Late --> Severe Late --> Severe Delayed, diminished carotid upstroke - Severe Sustained LV apical impulse, S4 gallop – Moderate to severe

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

14. Obtaining an Echocardiogram: Aortic Stenosis Indications Class Reassessment of asymptomatic patients with IIa Reassessment of asymptomatic patients with IIa mild to moderate AS and LV dysfunction or hypertrophy Reassessment of asymptomatic patients with stable III 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 Mild AS Every 5 years Moderate AS Every 2 years Moderate AS Every 2 years Severe ASAnnually Severe ASAnnually

16. Chronic Mitral Regurgitation Pathophysiologic mechanisms Mitral valve leafletsMitral valve leaflets Papillary musclesPapillary muscles Chordae tendinaeChordae tendinae AnnulusAnnulus Classic murmur High pitched, blowing, holosystolic murmur at the apexHigh pitched, blowing, holosystolic murmur at the apex Radiates to the axilla or left sternal borderRadiates to the axilla or left sternal border

17. Assessing MR Severity by Exam Mild MR Normal carotid upstroke Normal carotid upstroke Normal LV apical impulse Normal LV apical impulse Heart Sounds Heart Sounds Normal intensity of S1 Normal intensity of S1 Grade 1-2 murmur Grade 1-2 murmur Moderate-Severe MR Carotid pulse - Brisk upstroke Carotid pulse - Brisk upstroke Hyperdynamic, displaced LV apical impulse Hyperdynamic, displaced LV apical impulse Heart Sounds Heart Sounds Soft S 1Soft S 1 S 2 widely splitS 2 widely split S 3 gallopS 3 gallop

18. Obtaining a TTE: Chronic Mitral Regurgitation Indications Class Baseline evaluation to quantify severity of MR I Baseline evaluation to quantify severity of MR I and assess LV function Determine the mechanism of MR I Determine the mechanism of MR I Annual or semi-annual surveillance of LV function I Annual or semi-annual surveillance of LV function I in asymptomatic severe MR To establish cardiac status after a change in sxs I To establish cardiac status after a change in sxs I Evaluation post MVR to establish baseline status I Evaluation post MVR to establish baseline status I Routine f/u evaluation of mild MR with normal III 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. 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. Echocardiography is an important noninvasive method for assessing the significance of cardiac murmurs and to define cardiac structure and function.