1. Cardiac Exam II
16 October 2018

2. Goals Continue to add meaning to your cardiac examination
Incorporate immediate reinforcement via simulation (Harvey)

3. Objectives Understand the causes and timing of S3
Compare common causes of systolic murmurs (continued)
Distinguish innocent/physiologic from pathologic murmurs
Distinguish common diastolic murmurs and sounds
Identify the pericardial friction rub
Delineate techniques for accentuating murmurs

4. Diastolic Adventitious Sounds
S3 and S4
Bates' Guide to Physical Examination and History Taking, 11e, 2012

5. Causes of S3 Rapid deceleration of blood against ventricular wall
May be normal in healthy children and young adults
Left or right ventricular dysfunction
High volume
Mitral/tricuspid regurgitation
High flow
Anemia
Thyrotoxicosis
Pregnancy
Bates' Guide to Physical Examination and History Taking, 11e, 2012

6. Causes of S3 Rapid deceleration of blood against ventricular wall
May be normal in healthy children and young adults
Left or right ventricular dysfunction
High volume
Mitral/tricuspid regurgitation
High flow
Anemia
Thyrotoxicosis
Pregnancy
Bates' Guide to Physical Examination and History Taking, 11e, 2012

7. Causes of S4 Audible atrial contraction
Marker of change in ventricular compliance
Associated with stiff ventricle
Hypertrophic ventricle
Hypertension
Aortic stenosis
Hypertrophic cardiomyopathy
Acute myocardial ischemia
Bates' Guide to Physical Examination and History Taking, 11e, 2012

8. Causes of S4 Audible atrial contraction
Marker of change in ventricular compliance
Associated with stiff ventricle
Hypertrophic ventricle
Hypertension
Aortic stenosis
Hypertrophic cardiomyopathy
Acute myocardial ischemia
Bates' Guide to Physical Examination and History Taking, 11e, 2012

9. Opening snap Mitral/tricuspid stenosis
Audible sound due to restricted valve leaflet motion
Bates' Guide to Physical Examination and History Taking, 11e, 2012

10. Harvey Mitral Area (apex) with BELL How many sounds do you hear?
Three
Which one is louder?
First
Is that normal at this location?
Only if young (<30)
#44  #46

11. Harvey “Ken---------------TUCK-------eh”
“Lub dup-----boom”
“Rush ing------in”
#46

12. Harvey Mitral Area (apex) with BELL How many sounds do you hear?
Three
Which one is loudest?
Second (S1)
Is that third sound normal at this location? NO
#44  #36

13. Harvey “Ten-nes----------see” or really "te NUS….see”
“Huh-one two”
“A STIFF heart”
#36

14. Harvey Acute Anterior MI Mitral Area (apex) with BELL
How many sounds do you hear?
Four
Which one is louder?
S2—the ventricle has decreased ventricular contraction, so valves (M and T) closes slower and S1 is softer
Is hearing four sounds normal at this location?
No!
#44  #40

15. 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

16. Systolic Murmur Review – last week
Aortic Stenosis
Mitral Regurgitation
#13 #8
Location
2nd right intercostal
Radiation
Carotids, down sternal border, apex
Intensity
Can be Grade 4 or greater (thrill)
Pitch
Medium
Quality
Harsh; crescendo-decrescendo
Maneuvers
Sitting and leaning forward
Associated findings
Delayed carotid upstroke
Mechanism
Turbulence and decreased flow across aortic valve
Location
Apex
Radiation
Left axilla
Intensity
Similar
Pitch
Medium to high
Quality
Harsh; holosystolic
Maneuvers
Isometric handgrip
Associated findings
Apical S3, PMI changes
Mechanism
Failure of mitral valve to fully close in systole

17. With SEM, there is no
murmur sound during
Isovolumic contraction

18. Systolic Murmur Review
Hypertrophic cardiomyopathy
Congenital condition
Massive ventricular hypertrophy (PMI)
Rapid left ventricular ejection (carotid upstroke)
Variable outflow obstruction (mid-systolic murmur)
Increased with standing and Valsalva
Risk for syncope and sudden cardiac death

19. HOCM MRI

20. Systolic Murmur Review
Innocent
Physiologic
Location
2nd-4th left intercostal
Radiation
Little
Intensity
Grade 1-2, possibly 3
Pitch
Soft to medium
Quality
Variable
Maneuvers
Decreased or absent with standing
Associated findings
None
Mechanism
Turbulent blood flow from strong ventricular ejection
Location
Similar
Radiation
Intensity
Pitch
Quality
Maneuvers
Associated findings
Signs of associated condition
Mechanism
High flow in anemia, pregnancy, fever, hyperthyroidism

21. 23 yr old athlete passed out while playing basketball
Harvey
23 yr old athlete passed out while playing basketball #1

22. What do you hear at each area?
Harvey
What do you hear at each area?
Aortic area
Pulmonic area
Tricuspid area
Mitral area #1

23. Harvey Features? What kind of murmur? Where does it radiate?
Harsh crescendo-decrescendo systolic ejection murmur
Where does it radiate?
Apex (never carotids)
How can the murmur be changed?
Position (standing vs squatting)
Standing = LOUDER
Squatting = SOFTER #1

24. 18 yr old Healthy male College physical No Symptoms
Harvey
18 yr old Healthy male College physical No Symptoms
#22

25. What do you hear at each area?
Harvey
What do you hear at each area?
Aortic area
Pulmonic area
Tricuspid area
Mitral area
#22

26. Harvey Features? What kind of murmur? Where does it radiate?
Soft, crescendo-decrescendo systolic ejection murmur
Where does it radiate?
Usually nowhere
How can the murmur be changed?
Disappears with standing
#22

27. Diastolic Murmurs Key features Key features 2nd-4th left intercostal
Aortic regurgitation
Mitral stenosis
Key features
2nd-4th left intercostal
High-pitched
Blowing decrescendo
Patient leaning forward
Widened pulse pressure
Bounding arterial pulses
Key features
Apex
Low-pitched
Decrescendo rumble
Left lateral decubitus
Accentuated S1
Opening snap
Bates' Guide to Physical Examination and History Taking, 11e, 2012

28. Harvey
36 yr old male SOB BP 160/50 increased pulse pressure brisk peripheral pulses
#17

29. What do you hear at each area?
Harvey
What do you hear at each area?
Aortic area
Pulmonic area
Tricuspid area
Mitral area
#17

30. Harvey Features? What kind of murmur? Quality? Location/position?
Decrescendo diastolic murmur
Quality?
High-pitched and blowing
Location/position?
Left sternal border, 3rd/4th ICS
Patient sitting up and leaning forward
Change in pulse?
Widening pulse pressure (>40 mmHg)
Bounding pulse with brisk upstroke and large amplitude
#17

31. Dyspneic female in late 40’s
Harvey
Dyspneic female in late 40’s #5

32. What do you hear at each area?
Harvey
What do you hear at each area?
Aortic area
Pulmonic area
Tricuspid area
Mitral area #5

33. Harvey Features? What kind of murmur? Quality? Position? #4
Diastolic rumble
Quality?
Low-pitched (bell)
Position?
Left lateral decubitus #4

34. HI Michelena, M Enriquez-Sarano. N Engl J Med 2018;379:e9.
Corrigan’s Pulse and Quincke’s Pulse
HI Michelena, M Enriquez-Sarano. N Engl J Med 2018;379:e9.

35. TF Imran, EH Awtry. N Engl J Med 2018;379:e6.
Severe Mitral Stenosis
TF Imran, EH Awtry. N Engl J Med 2018;379:e6.

36. Systolic/Diastolic Murmurs
Continuous
Venous hum
Turbulence in jugular veins
Loudest in diastole
Above medial third of clavicle, particularly on right
Patent ductus arteriosus
Open channel between aorta and pulmonary artery
Machinery-like
2nd left intercostal
Non-continuous
Pericardial friction rub
Inflammation of pericardial sac

37. Pericardial Friction Rub
Timing: 3 components
Atrial systole (late diastole)
Ventricular systole (mid-to-late systole)
Ventricular diastole (early-to-mid diastole)
Location: variable; 3rd left interspace
Radiation: little
Intensity: variable
Pitch: high
Quality: scratchy
Aids: patient leaning forward; “Hering” position

38. Harvey
Healthy adult female
#28

39. What do you hear at each area?
Harvey
What do you hear at each area?
Aortic area
Pulmonic area
Tricuspid area
Mitral area
#28

40. Harvey Features? What kind of murmur? Quality? Radiation? #28
Continuous
Quality?
Loud, harsh, machinery-like
Radiation?
Clavicle
#28

41. Harvey
38 yr old presenting to ED 1 day of sharp pleuritic chest pain relieved by leaning forward
Preceded by 5 days of URI sxs, low grade fevers, and myalgias
#30

42. What do you hear at each area?
Harvey
What do you hear at each area?
Aortic area
Pulmonic area
Tricuspid area
Mitral area
#30

43. Accentuating Murmurs Standing/squatting Valsalva maneuver
Isometric handgrip

44. Accentuating Murmurs Standing/squatting Standing Squatting
Decreased venous return
Decreased peripheral vascular resistance
Decreased left ventricular volume
Increased mitral valve prolapse with earlier systolic click
Increased hypertrophic cardiomyopathy murmur
Decreased innocent murmurs
Squatting
Increased venous return
Increased peripheral vascular resistance
Increased aortic stenosis murmur

45. Accentuating Murmurs Valsalva maneuver
Forcible expiration against closed glottis
“Bear down”
Increased intrathoracic pressure
Increased outflow tract obstruction
Increased hypertrophic cardiomyopathy murmur

46. Accentuating Murmurs Isometric handgrip
Increased arterial blood pressure
Increased mitral regurgitation
Increased aortic regurgitation
Increased mitral stenosis

47. Summary

48. Third Heart Sound-Review
LV S3 so low frequency may require work at to hear; RV S3 varies with respiration
RV S3
(increases
with inspiration)
LV S3 S1 S2 S3
“KEN TUCK Y”
LV/RV dysfunction
High volume conditions
Mitral/tricuspid regurgitation
High-flow states
Anemia
Thyrotoxicosis
Pregnancy
Abnormal presence
Timing: Following S2 (distant from
down-stroke of carotid pulse)
Changes: Age Normal presence
< % % %
 %

49. Fourth Heart Sound-Review
Another low frequency, late diastolic sound during atrial contraction in a poorly compliant ventricle. Can be augmented with handgrip. RV S4 will vary with respiration S4
RV S4
(increases
with inspiration)
LV S4 S1 S2
“TENN ESSEE”
Abnormal presence
Timing: Immediately preceding S1 and
upstroke of carotid pulse
Hypertrophic ventricle
Hypertension
Aortic stenosis
HOCM
Ischemia
Location: Apex at the xiphoid and left
lower sternal border

50. Heart sounds by TIMING S2 Split S2 (0.04s) S4 (0.12-0.16s before S1)
Opening Snap ( s)
S3 ( s)
S4 ( s before S1) S1
Split S1 ( s)
Ejection click S4 S3
Midsystolic
click(s)
split
split OS EC S2 S1

51. Accentuating Murmurs Standing/squatting Valsalva maneuver
Mitral valve prolapse
Hypertrophic cardiomyopathy
Aortic stenosis
Innocent murmurs
Valsalva maneuver
Isometric handgrip
Mitral regurgitation
Aortic regurgitation
Mitral stenosis

52. Murmurs Aortic stenosis Mitral regurgitation Aortic regurgitation
Systolic
Diastolic
Aortic stenosis
Mitral regurgitation
Aortic regurgitation
Mitral stenosis

53. Pericardial Friction Rub
Systolic (1) and diastolic (2) components
Unique scratchy quality

54. Essential Auscultation 54

55. Real heart sounds
Blaufuss Multimedia:

56. Questions?