How to Examine the Heart Just The Essentials

Joel Niznick MD FRCPC

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Stages of Learning
Unconscious incompetence Conscious incompetence Conscious competence Unconscious competence

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How to Examine the Heart

Examine the heart from peripheral to central putting the pieces of the puzzle together as you go By the time you put the stethoscope on the chest you should know what you will hear Dont leave the bedside and then try to figure out what youve heard. Be certain before the exam is over.
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Inspection
Go with the probabilities
Long thin people have long thin valves (MVP) Males more likely to have aortic valve disease
Young-think bicuspid aortic valve Middle age-think rheumatic AV disease Elderly -think degenerative AV disease

Females- think mitral valve disease

MVP much more common than rheumatic MV disease
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Marfans Syndrome
Body Habitus Tall/thin/long facies Long fingers
Thumb sign Wrist sign

Aortic dissection
Dilatation of the aorta affecting sinuses of valsalva MVP Mitral regurgitation LV dilatation Dilated pulmonary artery < age 40 MAC < age 40

Ligamentous laxity Scoliosis/kyphosis Pectus excavatum/carinatum Ectopia lentis Narrow long facies High arched palate
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RECOMMENDED BLOOD PRESSURE MEASUREMENT TECHNIQUE

The Thecuff cuffmust mustbe belevel levelwith withheart. heart. If arm circumference exceeds If arm circumference exceeds 33 33cm, cm, aalarge largecuff cuff must mustbe beused. used. Place Placestethoscope stethoscopediaphragm diaphragmover over brachial artery. brachial artery.

2. 2.

1. 1.
The Thepatient patientshould should be relaxed be relaxedand andthe the arm must be arm must be supported. supported. Ensure Ensureno notight tight clothing constricts clothing constricts the thearm. arm.
Stethoscope

Mercury machine

The Thecolumn columnof of mercury mercurymust mustbe be vertical. vertical. Inflate Inflateto toocclude occludethe the pulse. Deflate at 2 pulse. Deflate at 2to to 33mm/s. Measure mm/s. Measure systolic systolic(first (firstsound) sound) and anddiastolic diastolic (disappearance) (disappearance)to to nearest 2 mm Hg. nearest 2 mm Hg.

3. 3.

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BP Treatment Targets
160/100 < 140/90
< 135/85

Condition
Treatment threshold if no risk factors, TOD or CCD Treatment target for office BP measurement
Treatment target for for ABP or HBP measurement Treatment target for for Type 2 diabetics or non-diabetic nephropathy Treatment target for non-diabetic nephropathy with proteinuria

< 130/80

< 125/75

What are the indications for checking the BP in both arms?

The presence of both arms
R/O Atherosclerotic obstruction Scalenus anticus syndrome/cervical rib Aortic coarctation above left subclavian Anomalous origin right subclavian artery in aortic coarctation

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What are the indications for checking BP in the lower extremities?

Hypertensive patient under 40 years of age. Elderly patient with suspected PVD

How do you do it?

Thigh cuff-auscultate over popliteal artery Large arm cuff around calf (bladder posterior) -palpate PT or DP

Which is normally higher- arm or leg BP?

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Ankle-brachial index
Resting and post exercise SBP in ankle and arm.
Normal ABI > 1 ABI < 0.9 has 95% sensitivity for angiographic PVD ABI 0.5- 0.84 correlates with claudication ABI < 0.5 indicates advanced ischaemia

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Palpation-Pulses
Rhythm, rate, regularity Contour Water hammer pulse-AR Brachial-radial delay AS Pulsus paradoxus
Tamponade COPD

Pulsus alternans
LV dysfunction
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Carotid Examination
Carotid upstroke
brisk, normal or delayed bisferiens or anacrotic volume: normal, increased or decreased

Carotid auscultation
Bruit Transmitted murmur A2 audible in neck? Presence excludes severe AS
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JVP Inspection
Height Waveform Differentiate from carotid Descents are easier to see due to greater amplitude and frequency Specific patterns Maneuvers

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Normal JVP Waveform

Consists of 3 positive waves a,c & v And 3 descents x, x'(x prime) and y
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Jugular venous pressure

Level of sternal angle is about 5 cm above the level of mid right atrium IN ANY POSITION. JVP is measured in ANY position in which top of the column is seen easily. Usually JVP is less than 8 cm water
< 3 cm column above level of sternal angle.
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Use the hand made ruler

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Normal JVP Waveform

a wave - atrial systole x' (prime) descent !!! occurs during systole due x descent onset of to RV contraction pulling down the TV valve ring atrial relaxation descent of the base c wave - small a measure of RV contractility positive notch in the 'x' descent due to bulging v wave - after the x' descent - slow positive of the AV ring into the wave due to right atrial atria in ventricular filling from venous return contraction. y descent - rapid
emptying of the RA into RV due to TV opening
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JVP Summary
Its easier than it looks !!! Look for descents not waves Time deepest descent with systole This is the x' (prime) descent !!!
Occurs during systole due to RV contraction pulling down the TV valve ring descent of the base A measure of RV contractility

If the dominant descent is systolic-this is the x' descentand JVP waveform is normal
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Identifying the Waveform

If the dominant descent is systolic-this is the x' descent-and JVP waveform is normal The a wave is inferred as the positive wave before the dominant descent The y descent is sometimes seen but is not as deep as x' descent
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The c wave never seen The y descent sometimes seen

Diastolic descent Shallower than X'

The v wave is inferred as the positive wave between x' and y The x descent rarely seen
visible in 1o heart block
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JVP- HJR & Kussmauls sign

Hepato-jugular reflux (various definitions)
sustained rise 1 cm for 30 sec. venous tone & SVR RV compliance

JVP normally falls with inspiration Kussmauls sign

inspiratory in JVP constriction rarely tamponade RV infarction

Positive HJR correlates with LVEDP > 15

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Specific JVP patterns

Condition
Normal waveform
Post CABG Atrial fibrillation

Pattern
X' deeper than Y
X' shallower, now = Y CV wave

Tricuspid regurgitation
Complete heart block

CV wave
Irregular cannon A waves

Tamponade
Constriction RV infarction Continuing Medical Implementation

JVP brisk X' > Y

JVP brisk X' & Y descents X' less exaggerated than Y JVP low amplitude .. .bridging the care gap

Precordium-Palpation
Parasternal Lift: RVE or severe MR Thrill: VSD, HOCM (IHSS) Palpable P2 (ULSB): pulmonary hypertension Medial retraction LVE Lateral retraction RVE
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Palpation - Apex
Apex:
Palpable in 1 of 5 adults age 40 Best felt with fingertips or finger pads Normal Location: No more than 10 cm from mid-sternal line in the supine position Left decubitus position not reliable for apical location Normal Size: No larger than 3 cm (about 2 finger breadths)
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Apex-Dynamic Qualities
LV impulse outward movement like a ping pong ball were protruding between the ribs Apex moves outward for the first third of systole and falls away rapidly Lasts for no more than 2/3 of systole Sustained apex-hangs out to S2

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ApexDynamic Abnormalities
Sustained Apex: correlates with pressure overload ( > 2/3 systole-hangs out to S2) AS, LVH or LV systolic dysfunction Hyperdynamic Apex: correlates with volume overload AR/MR Palpable S4 (atrial kick) stiff LV Palpable S1 (MS) Palpable non-ejection click (MVP)
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ApexDynamic Abnormalities
Atrial kick: Palpable S4
Loss of LV compliance LVH 2o Hypertension Aortic Stenosis Hypertrophic Cardiomyopathy

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Auscultation
Use the diaphragm for high pitched sounds and murmurs Use the bell for low pitched sounds and murmurs Sequence of auscultation
upper right sternal border (URSB) upper left sternal border (ULSB) lower left sternal border (LLSB) apex apex - left lateral decubitus position lower left sternal border (LLSB)- sitting, leaning forward, held expiration
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www.blaufuss.org Used with permission

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Heart Sounds
S1 closure of mitral valve S2 closure of aortic (A2) and pulmonary valves (P2) S4 pre-systolic sound
atrial contraction filling non-compliant ventricle Low pitched, bell, apex

S3 early diastolic filling of volume overloaded ventricle

Low pitched, bell, apex
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Auscultation
Exclude S3 Lower pitched A2/P2 Heard with bell A2/Pericardial knock At apex A2/OS In left decubitus Sometimes 3 components: position Differential diagnosis of split S2:
A2/P2/OS A2/P2/PK

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Use your built in heart sound simulator

Drum fingers on chest or table Auscultate with stethoscope
Ring finger S4 Middle finger S1 Index finger S2 Thumb finger S3

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Assessing Murmurs
Grading of Murmurs: Grade 1 - only a staff man can hear - faint Grade 2 - audible to a resident need to focus to hear Grade 3 - audible to a medical student easily heard Grade 4 - associated with a thrill or palpable heart sound Grade 5 - audible with the stethoscope partially off the chest Grade 6 - audible at the bed-side
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Innocent Murmurs
Common in asymptomatic adults
Characterized by
Grade I II @ LSB Systolic ejection pattern - no with Valsalva

S1 S2 Normal precordium, apex, S1 Normal intensity & splitting of second sound (S2) No other abnormal sounds or murmurs No evidence of LVH
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Characteristic of the NOT Innocent Murmur

Diastolic murmur Loud murmur - grade 4 or above Regurgitant murmur Murmurs associated with a click Murmurs associated with other signs or symptoms e.g. cyanosis Abnormal 2nd heart sound fixed split, paradoxical split or single
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Auscultation
Aortic area
2nd left intercostal space (URSB)
compare S1 to S2-S1 should be softer. If the same, think Mitral Stenosis identify ejection murmur-time the peak intensity in relation to systole identify ejection click if present

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Auscultation
Pulmonary Area 2nd right intercostal space (ULSB)
listen for split S2 (A2/P2) identify the intensities of A2 and P2 time split S2 with respiration
normally widens with inspiration, closes with expiration wide split S2-RBBB, RV volume overload,PS, RV failure wide fixed split = ASD paradoxical split = LBBB, severe AS, severe LV dysfunction, pacemaker

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Auscultation
Left Sternal Border Listen for early diastolic murmurs (AR/PR) Press firmly with diaphragm Listen upright with forced expiration Listen on hands and knees

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Auscultation
Mitral Area (LLSB)
Listen for intensity of S1
Soft S1 -LV dysfunction, first degree heart block, preclosure with sudden severe AR/MR Loud S1 -MS, sympathetic stimulation Variable S1 - Complete heart block with AV dissociation, Wenkebach

Identify splitting of S1(differential)

M1/T1, M1/EC(aortic or pulmonary) , M1/Non-EC (MVP), S4/M1
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Auscultation
Mitral Area (LLSB) Identify quality,timing and intensity of systolic murmurs
ejection quality vs regurgitant quality pansystolic vs early or mid to late systolic murmer

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Auscultation
Apex
Listen for S3 and S4 Consider differential diagnosis of S3
A2-wide P2, A2-OS, A2-PK, A2-S3

Identify diastolic rumble Determine radiation of murmur e.g.. MR to axilla

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AuscultationTiming of A2 to OS Interval
Width of A2-OS inversely correlates with severity The more severe the MS the higher the LAP the earlier the LV pressure falls below LAP and the MV opens
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Say Prrr Pada Pata Papa Tuhuh

Timing Severity Other seconds of MS HSs 0.06 Severe .07-.08 .08-.09 0.10 .12 Modsevere Mod Mild PK
0.1-0.110

A2-S3
0.12-0.18

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Clinical Signs of LV Dysfunction

Hypotension Pulsus alternans Reduced volume carotid LV apical enlargement/displace ment Sustained apex - to S2
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Soft S1 Paradoxically split S2 S3 gallop (not S4 = impaired LV compliance) Mitral regurgitation Pulmonary congestion
rales
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Clinical Signs of RV Dysfunction

With Pulmonary HPT
Loud P2/palpable PR murmer RV lift

Without Pulmonary HPT

Soft P2 No PR +/- RV lift
TR CV wave murmer Pulsatile liver Edema

Common findings

RV S4 RV S3 JVP A wave + HJR + Kussmauls

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Common Murmurs and Timing

Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis
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S1

S2 S1 .. .bridging the care gap

Aortic Stenosis: Physical Findings

S1

S2

S1
Severe

S2

Mild-Moderate

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Aortic Stenosis: Physical Findings

Intensity DOES NOT predict severity Presence of thrill DOES NOT predict severity Diamond shaped, harsh, systolic crescendodecrescendo Decreased, delay & prolongation of pulse amplitude Paradoxical S2 S4 (with left ventricular hypertrophy) S3 (with left ventricular failure)
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Recognizing Aortic Stenosis

Sign JVP-prominent A wave Carotid-delayed, anacrotic A2 audible over carotids Apex- sustained, atrial kick -enlarged, displaced Thrill Cardiomegaly- Clinical/CXR Soft S1 Paradoxical S2 S3, S4 SEM- intensity - late peak ECG- LAE, LVH Correlation with Severity No Yes If A2 transmitted to carotids mean AV gradient 50 mm Hg and stenosis not severe Yes Yes No Yes Yes Yes Yes No Yes Yes
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