Cardiovascular Physical Exam Pearls

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Cardiovascular Physical Exam Pearls

• Daniel J. ORourke, MD
• Cardiology Symposium
• December 2004

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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

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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)

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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)

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Overview of Murmurs

• 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

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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

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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

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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 gt Grade III
• Absence of concomitant cardiac pathology

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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

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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
• AVA Mean Gradient
• Mild gt1.5 cm2 lt25 mmHg
• Moderate 1.0-1.4 25-49 mmHg
• Severe lt1.0 gt50 mmHg

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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

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Assessing AS Severity by Exam

• Splitting of S2
• Physiologic --gt Mild
• Single --gt Mod/Severe
• Paradoxical --gt Severe

• Murmur Peak
• Early-mid --gt Mild
• Mid-late --gt Moderate
• Late --gt Severe

Sustained LV apical impulse, S4 gallop Moderate
to severe
Delayed, diminished carotid upstroke - Severe
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Obtaining an Echocardiogram Aortic Stenosis

• Indications Class
• 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 1998321486-1588.
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Obtaining an Echocardiogram Aortic Stenosis

• Indications Class
• 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 1998321486-1588.
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Frequency of Surveillance Echo

• Asymptomatic, clinically stable patients
• Mild AS Every 5 years
• Moderate AS Every 2 years
• Severe AS Annually

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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

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Assessing MR Severity by Exam

• 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

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Obtaining a TTE Chronic Mitral Regurgitation

• Indications Class
• 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 1998321486-1588.
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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.