Cardiac Valvular Exam

Ways to think about murmurs/extra sounds:

◦Divide them by timing ◦Systole vs Diastole ◦Divide them by valve pathology ◦Aortic stenosis vs aortic regurgitation

RELEASE phase of valsalva maneuver HOCM

murmur DECREASES (gets softer) ◦Increased blood flow to heart - more blood stretching left ventricle - pushes hypertrophied septum out of outflow tract (less obstruction) --> SOFTER

APT-ME 2245-3

A = Aortic 2nd ICS Right P = pulmonic 2nd ICS Left T = Tricuspid 4th ICS Left M = Mitral 5th ICS MCL E = Erb's point 3rd ICS left

STRAIN phase of Valsalva maneuver HOCM

murmur INCREASES (gets louder) ◦Decreased blood flow to heart - less blood stretching left ventricle - hypertrophied ventricular septum further overrides aortic outflow tract (more obstruction) --> LOUDER

Regurgitation

Abnormal backflow ◦Regurgitation murmur will happen when the blood SHOULDN'T be flowing through the valve

Stenosis

Abnormal narrowing ◦Stenosis murmur will happen when the blood SHOULD be flowing through the valve

Water hammer pulse

Associated with aortic regurg

Murmur pitch

Associated with velocity of the blood: ◦High ◦Medium ◦Low

Pulmonic Regurgitation- Graham Steell murmur

- when d/t pulm HTN w/o valve pathology Timing - Diastolic Intensity - Variable Pitch: Low to medium Quality: Blowing - Decrescendo Heard best: 2nd or 3rd Left ICS Radiation: none Augmenting Maneuver: Increases with inspiration

Pulsus tardus

On auscultation with aortic stenosis ◦Gentle, sustained (drawn out), gradual carotid upstroke that occurs late in systole ◦Compare to normal carotid pulse ◦Brisk upstroke, pulsatile tapping

Aortic RegurgitationAustin Flint Murmur (severe)

Timing - Diastolic Intensity - grade 1-4 Pitch: High Quality: Blowing - Decrescendo Heard best: Left 2nd-4th ICS Radiation: apex Augmenting Maneuver Patient sitting, leaning forward, breath held after full exhalation ◦Associated Exam finding: ◦Corrigan pulse / water hammer pulse

Mitral Stenosis

Timing - Diastolic Intensity: Grade 1-4 Pitch: Low: Quality Rumbling Decrescendo Heard best: Apex Radiation - none Augmenting Maneuver Patient in left lateral decub, with isometric handgrips, in full exhalation, with bell Opening Snap immediately after S2 (at start of the murmur)

Tricuspid Regurgitation

Timing - Systolic Intensity - variable Pitch: Medium Quality: Blowing - Holosystolic Heard best: LLSB Radiation: To right sternal border, xiphoid Augmenting Maneuver Intensity increases with inspiration Associated findings: ◦Increased and/or sustained right ventricular impulse ◦Increases JVP from backflow

Pulmonic Stenosis

Timing - Systolic Intensity: Soft to loud Pitch: Medium Quality: Harsh -Crescendo-decrescendo Heard best: Left 2nd & 3rd ICS Radiation: Toward left shoulder/neck, if loud enough Associated findings: Ejection click in mild to mod stenosis Widely split S2 in severe stenosis S4 audible at LSB

Mitral Valve Prolapse (Click-Murmur)

Timing - systolic Intensity - variable Pitch: High Quality: Short, blowing - Midsystolic click followed by murmur Heard best: Apex Radiation: To left of spine Augmenting Maneuver Increased: Valsalva, handgrip, standing Decreased: squatting

Mitral Regurgitation

Timing - systolic Intensity: Loud Pitch: High Quality: Blowing Holosystolic Heard best: Apex Radiation: Soft - no radiation Loud - to axilla Augmenting Maneuver - none May have S3 audible at apex w/ laterally displaced, diffuse apical impulse

Study suggestions

◦Consider making a table/timeline with cardiac cycle, marking early/mid/late and placing each sound/murmur on the timeline ◦Make a large picture of the heart with the auscultation points ◦At each point, write in which sounds/murmurs are heard best at that spot ◦Going to help you when you're listening: ◦The location + timing = narrow your differential

Venous Hum

◦Continuous murmur: systole through diastole ◦Soft to moderate intensity ◦low-pitched ◦humming or roaring sound ◦Heard best above medial clavicle ◦With patient sitting upright ◦Disappears when supine ◦Radiates to R/L 1st & 2nd ICS ◦Caused by turbulent venous blood flow ◦Jugulars, subclavians dumping into SVC ◦Can be confused with Patient Ductus Arteriosus ◦Also is a continuous murmur, but not position dependent

Diastolic murmur intensity

◦1/4 : barely audible ◦2/4 : faint but immediately audible ◦3/4 : easily heard ◦4/4 : very loud

Systolic murmur intensity

◦1/6 : softer in volume than S1 & S2, very faint ◦2/6 : equal in volume to S1/S2, faint but heard immediately ◦3/6 : louder than S1/S2, moderately loud ◦4/6 : louder than S1/S2, with palpable thrill* ◦5/6 : louder than S1/S2, with thrill, may not need full contact of stethoscope ◦6/6 : louder than S1/S2, with thrill, may be heard with stethoscope off chest

Hypertrophic Cardiomyopathy

◦Aortic outflow obstruction murmur ◦Sounds like aortic stenosis ◦"medium pitched, harsh, holosystolic murmur" ◦Heard best at LEFT 3rd-4th ICS ◦Radiates DOWN LEFT STERNAL BORDER ◦Not to neck ◦Associated: S4 at audible at apex ◦Differentiated by augmentation maneuvers Associated findings: - Brisk carotid upstroke (unlike AS) - Sustained apical impulse - Apical S4 may be present

Isometric Handgrip maneuver

◦Ask patient to make fist and hold to fatigue ◦Squeeze hands together ◦Squeeze a washcloth ◦Increases afterload by increasing peripheral resistance ◦Arteries have clamped down

Opening snap (OS)

◦Associated with mitral stenosis ◦Caused by restricted (mitral) valve movement ◦Early diastolic ◦High-pitched (diaphragm) ◦Snapping quality ◦Heard best at LLSB ◦Can radiate to axilla or pulmonic area

Systolic clicks

◦Associated with mitral valve prolapse ◦Mid to late systolic sound ◦High-pitched, ◦sharp quality ◦Heard best at apex and/or LLSB

Innocent/Physiologic/Still's Murmur

◦Caused by turbulent blood flow • ◦Relatively forceful ventricular ejection ◦Temporary increase in blood flow ◦Anemia, fever, pregnancy, hyperthyroid state, ◦Common in children and young adults ◦Timing - Systolic ◦Intensity: Soft, usually 1-2/6 ◦Pitch: Soft to medium ◦Quality: variable ◦Heard Best: Left 2nd-4th ICS, LSB to apex ◦Radiation - minimal ◦Augmentation Maneuver ◦Decreases/disappears when sitting

Standing cardiac exam

◦Decreases venous return to heart & decrease peripheral vascular resistance

S3 extra sound

◦Early diastolic sound (shortly after S2) due to rapid ventricular filling ◦Low pitched and dull sounding ◦Can be physiologic or pathologic ◦Depends on patient population ◦Physiologic - children to young adults (~35 yrs), 3rd trimester preg, ◦Pathologic - decreased myocardial contractility, heart failure, ventricular overload (d/t atrial regurg) ◦Heard: ◦Left S3: apex in left lateral decub ◦Right S3: lower left sternal border (LLSB)

Murmur configuration (shape)

◦Essentially intensity + duration ◦Crescendo - increases in intensity ◦Decrescendo - decreases in intensity ◦Crescendo - Decrescendo ◦Plateau - stable intensity throughout

Valsalva maneuver

◦Forcible exhalation against closed glottis 4 phases: ◦Strain onset (decreased venous return) ◦Strain maintenance ◦Release (blood coming back to the heart) ◦Recovery ◦Most murmurs increase in intensity in RELEASE phase ◦more blood across valve --> LOUDER ◦and decrease in intensity in the STRAIN phase ◦less blood across valve --> SOFTER

Pericardial friction rub

◦From irritated pericardial or parietal pleura ◦Can occur at various or multiple points in cardiac cycle ◦Coarse grating, scraping or scratching sound, ◦high-pitched ◦Heard best: Left 3rd ICS (AKA _______) ◦Position patient sitting, leaning forward with breath held after full exhalation

Murmur duration

◦Holo- ◦Early ◦Mid ◦Late ◦Continuous - thru systole into diastole

Lying supine cardiac exam

◦Increase blood flow into heart ◦Modify by raising patient's legs ◦Further increase venous return

Bisferiens pulse

◦Increased systolic arterial pulse with a double peak - with aortic regurg

Isometric handgrip HOCM

◦Increases afterload, ventricle doesn't contract as much, more blood keeping outflow tract open ◦Murmur decreases

Squatting cardiac exam

◦Increases venous return & increases peripheral vascular resistance

Systolic murmurs

◦MR. TRASPS ◦Mitral Regurgitation ◦Tricuspid Regurgitation ◦Aortic Stenosis ◦Pulmonic Stenosis OR: ◦MR. PASS, MVP ◦Mitral Regurg, Physiologic, Aortic Stenosis, Systolic ◦Mitral valve prolapse ◦Tricuspid Regurg & Pulmonic Stenosis are inferred

Diastolic murmurs

◦MS. PRARTS ◦Mitral Stenosis ◦Pulmonic Regurgitation ◦Aortic Regurgitation ◦Tricuspid Stenosis OR: ◦MS. ARD ◦Mitral Stenosis, Aortic Regurgitation; Diastolic ◦You have to infer that tricuspid stenosis & pulmonic regurg included here Always pathologic!

Murmur Documentation Example

◦No heaves appreciated, PMI not visible. JVP is normal at 3cm above sternal angle at 30°. Carotid upstroke brisk without thrills, no audible bruit. PMI palpable at 5th ICS MCL, brief tapping. No palpable S1-S4. Palpation at pulmonic area and aortic area without appreciable impulses or pulsations. Crisp S1 and S2, with normal physiologic splitting. S1 louder at apex, S2 louder at base. No audible extra sounds in upright seated position. A soft early systolic murmur heard best at left 2nd ICS is noted. Murmur disappears with patient sitting up. With patient leaning forward, no audible murmurs. In left lateral decubitus, no extra heart sounds or audible murmur with diaphragm and bell

S4 (atrial gallop) extra sound

◦Occurs in late diastole, just before S1 ◦Low pitched and dull sounding ◦Can be physiologic or pathologic ◦Depends on patient population ◦Physiologic - athletes ◦Pathologic - increased ventricular resistance & stiffness d/t ventricular hypertrophy ◦Heard: ◦Left S4: apex in left lateral decub ◦Hypertensive cardiac disease, aortic stenosis, cardiomyopathies ◦Right S4: (uncommon) LLSB ◦Pulmonary hypertension, pulmonic stenosis

Murmur documentation outline:

◦Pitch ◦Quality ◦pattern ◦Timing ◦Heard best ◦Radiation if present ◦Augmentation maneuvers ◦A medium pitch, blowing holosystolic murmur heard best at LLSB with radiation to the RSB/xiphoid is noted. Murmur increases with inspiration.

Location of murmur

◦Point of maximal intensity ◦Can be audible at multiple auscultation points ◦Where murmur is heard best

Augmentation Maneuvers

◦Recall: normal cardiac exam in Semi-Fowler's ◦Positional Changes: Standing & Squatting & Supine

Murmur Radiation

◦Some, not all, murmurs will be audible at non-cardiac auscultation points ◦This finding helps characterize/narrow down cause of murmur

Tricuspid Stenosis

◦Timing - Diastolic ◦Intensity - variable ◦Pitch: Low to medium ◦Quality: Rumbling - Presystolic crescendo ◦Heard best: 2nd or 3rd Left ICS ◦Radiation - ◦Associated findings: ◦Giant a-waves in JVP ◦Differentiate from mitral stenosis by increased intensity with inspiration (right sided)

Aortic Stenosis

◦Timing - Systolic ◦Intensity: Most often loud (4+/6 with thrill) ◦Can be softer ◦Pitch: medium ◦Quality: Harsh whooshing ◦Crescendo-decrescendo ◦Heard best: Right 2nd & 3rd ICS ◦Radiation: Carotids ◦Augmenting Maneuver: Patient sitting, leaning forward

Ventricular Septal Defect (VSD)

◦Timing - systolic (ventricles contracting) ◦Intensity: Usually very loud ◦May be relatively quiet if small defect ◦Pitch: High ◦Quality: Harsh ◦holosystolic ◦Heard best: Left 3rd-5th ICS ◦Radiation - none