IM 3A: Cardiology

Dr. Jumangit
August 4, 2016

Differential
cyanosis

PHYSICAL EXAMINATION OF THE CARDIOVASCULAR SYSTEM

GENERAL PHYSICAL EXAMINATION
a.
b.
c.
d.
e.

General appearance
Age
Posture
Demeanor
Overall health status

Is the patient in pain or resting quietly, dyspneic or diaphoretic?

Does the patient choose to avoid certain body positions to reduce or
eliminate pain?

Chronically-ill appearing emaciated patient

- long standing heart failure or another systemic disorder such as a

malignancy
Height and weight should be measured
BMI should be calculated
Measure waist circumference and the waist-to-hip ratio

Various genetic syndromes (often with cardiovascular involvemen)t:

a. Trisomy 21 (Down Syndrome)
b. Marfan Syndrome
c. Holt-Oram Syndrome
Evidence of congenital heart disease:
hypertolerism
low-set ears
micrognathia
blue sclerae- feature of Osteogenesis Imperfecta
SKIN

Skin> Pallor, cyanosis and jaundice

Central Cyanosis

- significant R> L shunting at the level of the

Peripheral cyanosis
or acrocyanosis

heart or lungs
reduced extremity blood flow due to small vessel
constriction
severe heart failure
shock
peripheral vascular disease

Cardiology: Physical Examination of the Cardiovascular System

- isolated cyanosis affecting the lower but not the

upper extremities

- patient with large PDA secondary pulmonary

hypertension with R>L shunting at the great

vessel level (reversal of shunting)
Malar telangiectasis
mitral stenosis and scleroderma
Hemochromatosis - hereditary iron overload
- a common cause of restrictive cardiomyopathy
Jaundice
- with advanced right heart failure and congestive
hepatomegaly or late-term cardiac cirrhosis
- in patient taking Vitamin K antagonists or anti
Cutaneous
Ecchymoses
platelet
- subcutaneous xanthomas particularly along the
Lipid disorders
tendon sheaths or over the extensor surfaces of
the extremities
- specific for type III hyperlipoproteinemia
Palmar crease
xanthomas
- a disease associated with premature
Pseudoxanthoma
elasticum
atherosclerosis
- axilla and neck creases
HEAD AND NECK

- dentition and oral hygiene should be assessed in every patient both as a

source of potential infection and as an index of general health

- high-arched palate- is a feature of Marfan syndrome and other connective

tissue disease syndromes
High-arched palate
a feature of Marfan syndrome and other
connective tissue disease syndromes
Bifid uvula
Loeys-Dietz syndrome
Funduscopic
atherosclerosis
examination
hypertension
- assess the
DM
microvasculature
suspected endocarditis
CHEST
Midline sternotomy, left posterolateral thoracotomy, or infraclavicular scars
at the site of pacemaker/defibrillator generator implantation
Prominent venous collateral pattern- suggest subclavian or vena caval
obstruction

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EXTREMITIES

Thoracic cage abnormalities- connective tissue disease syndromes like

Marfan syndrome
pectus carinatum (pigeon chest)
pecuts excavatum (funnel chest)
Evidence of Obstructive lung disease
barrel chest deformity (inc AP diameter)
Pursed-lip breathing
use of accessory muscles
Ankylosing spondylitis
severe kyphosis and compensatory lumbar, pelvic, and knee flexion
should prompt careful auscultation for a murmur of aortic regurgitation
(AR)
dilatation of aortic ring with valvular insufficiency
Straight Back syndrome
loss of normal kyphosis of the thoracic spine
seen in MVP and its variants
PA may be compressed against the sternum gradient across
pulmonary outflow tract> ejection murmur
Respiratory rate and pattern should be noted during spontaneous breathing
depth
audible wheezing
stridor
Lung examination can reveal adventitious sounds indicative of pulmonary
edema, pneumonia, or pleuritis

Clubbing

shunting

- patients with endocarditis

- appearance can range from
!
Holt-Oram Syndrome

Marfan Syndrome

Elevated JVP
Arterial bruit

- arachnodactyly spider fingers abnormally long and slender fingers

- Positive "wrist" sign (overlapping of

-

- frequently enlarged in patients with chronic

heart failure

- systolic pulsations signify severe tricuspid

Splenomegaly
Ascites

regurgitation (TR)
- may be a feature of infective endocarditis
- advanced chronic right heart failure
- constrictive pericarditis
- hepatic cirrhosis
- Intraperitoneal malignancy
- implies cardiovascular etiology
- suggest high grade atherosclerotic disease,
though precise localization is difficult

the thumb and fifth finger around

the wrist)
Positive "thumb" sign (protrusion of
the thumb beyond the ulnar aspect
of the hand when the fingers are
clenched over the thumb in a fist)
sign.
Marfan syndrome are usually
associated with MVP and aortic
aneurysm

Mnemonic:
- (MARfan Mvp, AneuRysm)

!
Endocarditis lesions:

Cardiology: Physical Examination of the Cardiovascular System

cyanosis and softening of the root

of the nail bed, to the classic loss of
the normal angle between the base
of the nail and the skin
unopposable, "fingerized" thumb
frequently associated with atrial
septal defect (ASD)

ABDOMEN
Liver

- presence of central right-to-left

Janeway lesions:
- nontender, slightly raised
hemorrhages on the palms and
soles
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Oslers node:
- tender, raised nodules on the pads
of the fingers or toes

a-c-v waves
x-y descents

Splinter hemorrhages:
- linear petechiae in the mid position
of the nailed

- constrictive pericarditis

Pre sacral edema in the

setting of an elevated JVP
Lower extremity edema in the
absence of jugular venous
hypertension

- lymphatic or venous obstruction

- venous insufficiency

CARDIOVASCULAR EXAMINATION
JUGULAR VENOUS PRESSURE AND WAVE FORM
Jugular venous pressure

- the single most important bedside

measurement from which to estimate the
volume status
preferred because the external jugular
vein is valved and not directly in line with
the superior vena cava and right atrium.
has been used to discriminate between
high and low central venous pressure
(CVP)

Internal jugular vein

External jugular vein

Venous pressure

- the vertical distance between the top of

-

the jugular venous pulsation and the

sternal inflection point (angle of Louis)
A distance >4.5 cm at 30elevation is
considered abnormal

Cardiology: Physical Examination of the Cardiovascular System

A WAVE
- right atrial presystolic contraction
- occurs just after ECG P wave
- precede the first heart sound
- seen in reduced right ventricular
Prominent a wave
compliance
- cannon a wave occur with atrioventricular
(AV) dissociation and right atrial contraction
against a closed tricuspid valve
- wide ventricular tachycardia
- not present
Atrial fibrillation
X DESCENT
- defines the fall in right atrial pressure after inscription of the a wave
C WAVE
- interrupts this x descent and is followed by a further descent
- may reflect the carotid pulsation in the neck and/or an early systolic
increase in right atrial pressure as the right ventricle pushes the
closed tricuspid valve into the right atrium
V WAVE
- represents atrial filling (atrial diastole) during ventricular systole and
peaks at the second heart sound
- height determined by:
right atrial compliance
volume of blood returning to the right atrium either anterograde
from the cavae or retrograde through an incompetent tricuspid
valve

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Tricuspid regurgitation

ASSESSMENT OF BLOOD PRESSURE

- v wave accentuates
- subsequent fall in pressure (y
-

Accurate measurement depends on

body position
arm size
time of measurement

descent) is rapid
with progressive degrees of TR,
v wave merges with the c wave
the right atrial and jugular vein
waveform become
ventriculized

Y DESCENT
- follows peak of the v wave
- can become prolonged or blunted with obstruction to right ventricular
inflow, as may occur with tricuspid stenosis or pericardial tamponade
Kussmaul sign
- due to the impaired filling if right ventricle
- either a rise or a lack of fall of the JVP with inspiration
- associated with:
constrictive pericarditis
restrictive cardiomyopathy
massive pulmonary embolism
advanced left ventricular systolic heart failure
* normally the venous pressure should fall by at least 3 mmHg with
inspiration
ABDOMINOJUGULAR REFLEX
- elicited with firm and consistent pressure over the upper portion of the
abdomen preferably over the right upper quadrant, for at least 10 s.
- Positive response: sustained rise of more than 3 cm in JVP for at least
15 s after release of the hand.
- useful in predicting a pulmonary artery wedge pressure in excess of 15
mmHg in patients with heart failure.
ELEVATED JVP
- prognostic significance in patients with both symptomatic heart
failure and asymptomatic left ventricular systolic dysfunction.
- associated with a higher risk of subsequent hospitalization for
heart failure, death from heart failure, or both.

Blood pressure is best measured

- in the seated position
- with the arm at the level of the heart
- using an appropriately sized cuff:
the length and width of the blood pressure cuff bladder should be 80%
and 40% of the arm's circumference, respectively
- after 510 min of relaxation
Common source of error in practice
- marked overestimation of true BP
Inappropriately SMALL
cuff
- underestimation of true BP
Inappropriately LARGE
cuff

- The cuff should be inflated to 30 mmHg above the expected systolic

pressure and the pressure released at a rate of 23 mmHg/s.

- Systolic and diastolic pressures are defined by the first and fifth Korotkoff
sounds, respectively.

- Blood pressure is best assessed at the brachial artery level, though it can
be measured at the radial, popliteal, or pedal pulse level.

- In general, systolic pressure increases and diastolic pressure decreases

when measured in more distal arteries.

- Blood pressure should be measured in both arms, and the difference

should be less than 10 mmHg.

- A blood pressure differential that exceeds this threshold may be

Cardiology: Physical Examination of the Cardiovascular System

place of measurement
device
device size

associated with
atherosclerotic or inflammatory subclavian artery disease
supravalvular aortic stenosis
aortic coarctation
aortic dissection
Systolic leg pressures are usually as much as 20 mmHg higher than
systolic arm pressures.
Greater legarm pressure differences
chronic severe AR extensive and calcified lower extremity peripheral
arterial disease.
The ankle-brachial index
lower pressure in the dorsalis pedis or posterior tibial artery divided by
the higher of the two brachial artery pressures
powerful predictor of long-term cardiovascular mortality
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- The blood pressure measured in an office or hospital setting may not

accurately reflect the pressure in other venues.

WHITE COAT HYPERTENSION"

- at least 3 separate clinic-based &
- at least 2 non-clinic-based measurements <140/90 mmHg in the absence
of any evidence of target organ damage
- may not benefit from drug therapy
- may be more likely to develop sustained hypertension over time
ORTHOSTATIC HYPOTENSION
- a fall in systolic pressure >20 mmHg or in diastolic pressure >10 mmHg in
response to assumption of the upright posture from a supine position
within 3 min.
common cause of postural lightheadedness/syncope
exacerbated by advanced age, dehydration, certain meds, food,
deconditioning, and ambient temperature
ARTERIAL PULSE

- character and contour of the arterial pulse depend on the

- stroke volume
- ejection velocity
- vascular compliance
- systemic vascular resistance
- best appreciated at the carotid level
- A weak and delayed pulse (pulsus parvus et tardus) defines severe aortic

PERIPHERAL ARTERIAL PULSES

- subclavian, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and
posterior tibial.
In patients in whom the diagnosis of either temporal arteritis or polymyalgia
rheumatica is suspected, the temporal arteries also should be examined.
Although one of the two pedal pulses may not be palpable in up to 10% of
normal subjects, the pair should be symmetric.
A weak and delayed pulse (pulsus parvus et tardus) defines severe aortic
stenosis (AS).
PULSE IN AORTIC REGURGITATION
- With chronic severe AR, the carotid upstroke has a sharp rise and rapid
fall-off (Corrigan's or water-hammer pulse).
- Some patients with advanced AR may have a bifid or bisferiens pulse,
in which two systolic peaks can be appreciated.
BIFID PULSE
Described in patients with
hypertrophic obstructive
cardiomyopathy (HOCM)

easily appreciated in patients on

intra-aortic balloon counterpulsation
(IABP), in whom the second pulse is
diastolic in timing

stenosis (AS).

- The pulses should be examined for their

Symmetry
Volume
Timing
Contour
Amplitude
Duration

CAROTID PULSE
- Occurs just after the ascending aortic pulse
- simultaneous auscultation of the heart can help identify a delay in the
arrival of an arterial pulse
- The carotid upstrokes should NEVER be examined simultaneously or
before listening for a bruit
- Light pressure should always be used to avoid precipitation of carotid
hypersensitivity syndrome and syncope in a susceptible elderly individual.
AORTIC PULSE
- best appreciated in the epigastrium
- just above the level of the umbilicus
Cardiology: Physical Examination of the Cardiovascular System

PULSUS PARADOXUS
- a fall in systolic pressure of >10 mmHg with inspiration
- Seen in patients with:
pericardial tamponade
severe obstructive lung
disease
massive pulmonary
embolism
tension pneumothorax
hemorrhagic shock

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- measured by noting the difference between the systolic pressure at

which the Korotkoff sounds are first heard (during expiration) and the
systolic pressure at which the Korotkoff sounds are heard with each
heartbeat, independent of the respiratory phase.
Between these two pressures, the Korotkoff sounds are heard only
intermittently and during expiration.
The cuff pressure must be decreased slowly to appreciate the finding
It can be difficult to measure pulsus paradoxus
Tachycardia
Atrial fibrillation
Tachypnea
A pulsus paradoxus may be palpable at the brachial artery or femoral
artery level when the pressure difference exceeds 15 mmHg

PULSUS ALTERNANS
- defined by beat-to-beat variability of pulse amplitude.
- present only when every other phase I Korotkoff sound is audible as the
cuff pressure is lowered slowly
- typically in a patient with a regular heart rhythm
- independent of the respiratory cycle.
- seen in severe left ventricular systolic heart failure

Auscultation for carotid, subclavian, abdominal aortic, and femoral artery

bruits should be routine.
Cervical bruit = weak indicator of the degree of carotid artery stenosis;
- the absence of a bruit does not exclude the presence of significant
luminal obstruction.
The likelihood of significant lower extremity peripheral arterial disease
increases with presence of:
Claudication
Cool skin
Abnormalities on pulse examination
Presence of a vascular bruit
ABNORMAL PULSE OXIMETRY
- a >2% difference between finger and toe oxygen saturation
- used to detect lower extremity peripheral arterial disease
- comparable in its performance characteristics to the ankle-brachial index.

A visible right upper parasternal pulsation may be suggestive of ascending

aortic aneurysm disease.
PALPATION OF HEART
- begins with the patient in the supine position at
30
- can be enhanced by placing the patient in the
left lateral decubitus position.
- Thrill: palpable heart murmur felt
as a 'shudder' under the hand
- best felt with distal palm
- Heave: thrusting sensation often
used to describe large area
and amplitude with sustained
movement
LV IMPULSE
- less than 2 cm in diameter and moves quickly away
from the fingers
- better appreciated at end expiration, with the heart
closer to the anterior chest wall.
- enlargement of the LV cavity is manifested by a leftward and downward
displacement of an enlarged apex beat.
- Palpable presystolic impulse corresponds to the fourth heart sound (S4)
indicative of reduced left ventricular compliance and the forceful
contribution of atrial contraction to ventricular filling.
- Palpable third sound (S3)
indicative of a rapid early filling wave in patients with heart failure
may be present even when the gallop itself is not audible.
- Ventricular systole is defined by the interval between the first (S1) and
second (S2) heart sounds
HEART SOUNDS

INSPECTION AND PALPATION OF THE HEART

The left ventricular apex beat may be visible in the midclavicular line at the
fifth intercostal space in thin-chested adults.
Visible pulsations anywhere other than this expected location are
abnormal.
The left anterior chest wall may heave in patients with an enlarged or
hyperdynamic left or right ventricle.
Cardiology: Physical Examination of the Cardiovascular System

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NORMAL SOUNDS
NORMAL SOUNDS
- S1 Closure of MV and TV; loudest at apex
- S2 Closure of AV and PV; loudest at base
FIRST HEART SOUND (S1)
The intensity of S1 is determined by:
the distance over which the anterior leaflet of the mitral valve must
travel to return to its annular plane,
leaflet mobility,
left ventricular contractility
PR interval
SPLIT S1 - young patients
- right bundle branch block
- tricuspid valve closure is relatively delayed
LOUD S1
SOFT S1

- early phases of rheumatic mitral stenosis

- hyperkinetic circulatory states
- short PR intervals
ater stages of MS when the leaflets are rigid and calcified
after exposure to
-adrenergic blockers
long PR intervals
left ventricular contractile dysfunction

SECOND HEART SOUNDS (S2)

Aortic and pulmonic valve closure constitutes the second heart sound
- the A2P2 interval
NORMAL OR
increases with inspiration
PHYSIOLOGIC
and narrows during
SPLITTING
expiration.
WIDE
PHYSIOLOGIC
SPLITTING OF
S2

UNUSUALLY
NARROWLY
SPLIT OR
EVEN A
SINGULAR S2

- In right bundle branch

block because of the

further delay in pulmonic
valve closure
In severe MR because of
the premature closure of
the aortic valve
featre of pulmonary
hypertension

Cardiology: Physical Examination of the Cardiovascular System

FIXED
- secundum atrial defect
SPLITTING OF
S2
- pathologic delay in aortic
REVERSE
valve closure
PARADOXICAL
left bundle branch block
SPLITTING
right ventricular apical
(the individual
pacing
component of S2 are
audible at end
severe AS
expiration and
HOCM
intervals narrow with
acute myocardial
inspiration)
ischemia
THE THIRD HEART SOUND (S3)
- occurs during the rapid filling phase of ventricular diastole
- can be a normal finding in children, adolescents, and young adults
- in older patients it signifies heart failure
- low pitched sound best heard over the left ventricular
Left-sided S3
apex
Right-sided S3

- usually better heard over the lower left sternal border

and becomes louder with inspiration

THE FOURTH HEART SOUND (S4)

- occurs during the atrial filling phase of ventricular diastole
- indicates left ventricular presystolic expansion
- more common among patients who derive significant benefit from the
atrial contribution to ventricular filling
- in chronic left ventricular hypertrophy or active myocardial ischemia,
HOCM
- An S4 is not present with atrial fibrillation.
EJECTION SOUNDS

- a high-pitched early systolic sound that corresponds in timing to the

upstroke of the carotid pulse

Figure 1: normal physiologic

splitting
Figure 2: wide physiologic splitting

- associated with congenital bicuspid aortic or pulmonic valve disease;

- isolated aortic or pulmonary root dilation and normal semilunar valves
- becomes softer and then inaudible as the
Bicuspid Aortic Valve
valve calcifies and becomes more rigid.

Pulmonic Stenosis

- moves closer to the first heart sound as

the severity of the stenosis increases.

- It is the only right-sided acoustic event

that decreases in intensity with
inspiration

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NON EJECTION SOUNDS (CLICKS)

- related to mitral valve prolapse

- may be single or multiple
- may introduce a murmur
BEHAVIOR OF THE NONEJECTION CLICK (C) AND SYSTOLIC MURMUR
OF MVP
- With standing, venous
return decreases, the
heart becomes
smaller, and prolapse
occurs earlier in
systole
- The click and murmur
move closer to S1.

Pericardial
knock

Tumor
plop

opening snap, corresponding in

timing to the abrupt cessation of
ventricular expansion after
tricuspid valve opening and to an
exaggerated y descent seen in
the jugular venous waveform in
patients with constrictive
pericarditis.
a lower-pitched sound that rarely
can be heard in patients with
atrial myxoma

CARDIAC MURMURS

- With squatting,

venous return
increases, causing an
increase in left
ventricular chamber
size.
The click and murmur
occur later in systole
and move away from
S1

- high-pitched
- occurs slightly later than the

- Heart murmurs result from audible vibrations

-

that are caused by increased turbulence and

are defined by their timing within the cardiac
cycle
The duration, frequency, configuration, and
intensity of a heart murmur are dictated by the
magnitude, variability, and duration of the
responsible pressure difference between two
cardiac chambers, the two ventricles, or the
ventricles and their respective great arteries.

DIASTOLIC SOUNDS

- The high pitched opening snap (OS) of mitral stenosis (MS)

Opening
Snap of
MS

INTENSITY OF HEART MURMURS

- After the 2nd sound, there is a distinct, crisp extra sound

which is the opening snap (OS) of the stenotic mitral valve

- can be emulated saying "lup butter," adding an additional

syllable to the normal heart's "lup dup."

Cardiology: Physical Examination of the Cardiovascular System

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TIMING OF HEART MURMURS

Systolic Murmurs (Ventricular
Diastolic Murmurs (Ventricular Filling)
Pumping)
Restricted flow through narrow outflow Restricted filling through stenotic A-V
tract or vessel, or high flow through
valve or disturbed or high volume inflow
normal channel
mid-diastolic/presystolic
mid systolic
Regurgitation (backflow) through A-V
Regurgitation through semilunar valve
valve (MV,TV)
(Aortic, Pulmonic Valve)
holosystolic
early diastolic/holodiastolic
(occ. early or late systolic)
Flow through intracardiac defect(VSD)
holosystolic
Continuous (Shunt)
SYSTOLIC MURMURS
can be early, mid-, late, or holosystolic in timing

OTHER CAUSES:
pulmonic valve stenosis (with or without an ejection sound)
Hypertrophic obstructive cardiomyopathy
increased pulmonary blood flow in patients with a large ASD and
left-to-right shunting
accelerated blood flow in the absence of structural heart disease
(fever, thyrotoxicosis, pregnancy, anemia, and normal
adolescence)
B. LATE SYSTOLIC MURMURS
heard best at the apex, indicates MVP
may or may not be introduced by a non-ejection click
C. HOLOSYSTOLIC MURMURS
plateau in configuration
reflect a continuous and wide pressure gradient
Between the left ventricle and left atrium (chronic MR)
Between the left ventricle and right ventricle (VSD)
Between the right ventricle and right atrium (TR)
MR

- best heard over the cardiac apex.

- intensity of the murmur increases with maneuvers that increase
left ventricular afterload, such as sustained hand grip.

VSD
TR

- The murmur of VSD (without significant pulmonary hypertension)

-

is holosystolic and loudest at the mid-left sternal border, where a

thrill is usually present.
loudest at the lower left sternal border
increases in intensity with inspiration (Carvallo's sign)
accompanied by visible cv waves in the jugular venous wave
form and, on occasion, by pulsatile hepatomegaly

Mnemonic:
HOlocystolic MURmur (HOMUR)
HOMUR (Hammer)- VeSiDe (VSD), MisteR(MR)., ThoR (TR)
A. MID-SYSTOLIC MURMURS
begins after S1 and ends before S2
typically crescendo-decrescendo in configuration.
Aortic stenosis - most common cause of a midsystolic murmur in an adult
- Severe AS - would include parvus et tardus carotid upstrokes,
- a late-peaking grade 3 or greater midsystolic murmur, a soft A2, a
sustained LV apical impulse, and an S4.
- Inspection in AS: Carotid pulse peak is weak and delayed (parvus
et tardus)
- Auscultation in AS: murmur is mid systolic, murmur ends before S2,
ejection sound at 3rd right ICS
Cardiology: Physical Examination of the Cardiovascular System

Normal
MVP

- S1, S2, no murmurs

- mid systolic click, late systolic murmur of MR

Acute MR

- loud S1, initiates explosive systolic murmus

- S3 with mid-diastolic murmur

Chronic MR
(compensation)

- blowing holosystolic murmur

- mid diastolic rumble

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DIASTOLIC MURMURS
In contrast to some systolic murmurs, diastolic heart murmurs ALWAYS
signify structural heart disease
Usual causes of Diastolic murmurs:
Semilunar valve incompetence:
A-V valve obstruction:
Aortic insufficiency
Mitral stenosis
(regurgitation)
Pulmonic valve insufficiency
Tricuspid stenosis

CHRONIC SEVERE AR
Austin flint murmur:
low-pitched mid- to late apical
diastolic murmur that sometimes
can be confused with MS
Due to mitral inflow
Best heard at apex
Apical diastolic rumble imitating the
murmur of organic MS but is due to
aortic regurgitation (AR) stream that
prevents the mitral valve from
opening fully
PR (Pulmonic Regurgitation)

- classically heard as a
-

ACUTE AR
Inspection:
bounding (Corrigans) pulse
head bobbing (Mussets sign)
Auscultation
to-fro murmus
Mid systolic murmur (Aortic outflow)
Early diastolic murmur (Aortic
regurgitation)
3RICS (To-FRO)
2RICS (TO-fro)

- relatively soft and of short

duration

- rapid rise in left ventricular

diastolic pressure and the

progressive diminution of the
aortic-left ventricular diastolic
pressure gradient

Cardiology: Physical Examination of the Cardiovascular System

MS
Listening at base:
- abnormally loud S1 at base
- shorter S2-OS interval indicates MS
Listening at apex:
- crescnedo, pre systolic murmur
- loud S1
- S2, OS
- mid-diastolic murmur
Inspection:
- JVP is a wave dominant
- a wave occurs with loud S1

decrescendo, blowing
diastolic murmur
along the left sternal border in
patients with primary valve
pathology
along the right sternal border
in patients with primary aortic
root pathology.
pulse pressure is wide and the
arterial pulses are bounding in
character.
heard along the left sternal
border
most commonly due to
pulmonary hypertension and
enlargement of the annulus of
the pulmonic valve
S2 is single and loud and may
be palpable
right ventricular/parasternal lift
that is indicative of chronic
right ventricular pressure
overload.
classic cause of a mid- to late
diastolic murmur,
best heard over the apex in the
left lateral decubitus position
low-pitched or rumbling and is
introduced by an OS in the
early stages of the rheumatic
disease process.

FUNCTIONAL" MITRAL OR TRICUSPID STENOSIS

- generation of mid-diastolic murmurs that are created by increased and
accelerated transvalvular diastolic flow, even in the absence of valvular
obstruction
severe MR,
severe TR,
large ASD with left-to-right shunting

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Unusual causes of a mid-diastolic murmur

- include atrial myxoma,
- complete heart block, and
- acute rheumatic mitral valvulitis
CONTINUOUS MURMURS
- predicated on a pressure gradient that persists between two cardiac
chambers or blood vessels across systole and diastole.
- typically begin in systole, envelop the second heart sound (S2), and
continue through some portion of diastole.
Classic Example: Patent Ductus Arteriosus:
- usually heard in the second or third interspace at a slight distance from
the sternal border.
OTHER CONTINUOUS MURMURS
- ruptured sinus of Valsalva aneurysm with creation of an aorticright atrial
or right ventricular fistula
- a coronary or great vessel arteriovenous fistula, and
- an arteriovenous fistula constructed to provide dialysis access.
- Mammary souffle of pregnancy
enhanced arterial blood flow through engorged breasts
diastolic component of the murmur can be obliterated with firm pressure
over the stethoscope.
MURMUR EVALUATION
MANEUVERS THAT AFFECT MURMURS:
A. INSPIRATION (Mnemonic: R.I.ght- Inspiration; L.E.ft- Expiration)
Right-sided murmurs generally increase with inspiration.
Left-sided murmurs usually are louder during expiration
B. VALSALVA MANEUVER
Most murmurs decrease in length and intensity except:
HOCM: systolic murmur which usually becomes much louder
MVP: longer and often louder
After release of the Valsalva maneuver, right-sided murmurs tend to return
to control intensity earlier than do left-sided murmurs earlier into systole.
C. HANDGRIP
Most murmurs increase with exercise.
Murmurs of aortic stenosis or obstructive cardiomyopathy tend to
decrease with peak handgrip.
D. ARTERIAL-OCCLUSION
Blood pressure cuff inflation to both arms increases peripheral vascular
resistance.
Cardiology: Physical Examination of the Cardiovascular System

Augments the murmurs of ventricular septal defects and of mitral and

aortic regurgitation.
Opposite happens to AS
E. STANDING & SQUATTING
Squatting and passive leg elevation increases both venous return and
peripheral arterial resistance.
Standing diminishes most murmurs
Squatting or leg elevation increase most murmurs.
Standing intensifies the murmur of HOCM and prolongs mitral prolapse
murmur earlier into systole.
Squatting and leg elevation have opposite effects.
F. Post-PVC potentiation
Semilunar stenosis murmurs increase during the beat following a post
extrasystolic pause, or during beat following long RR interval in atrial
fibrillation.
Mitral regurgitant murmurs tend to remain unchanged, or even diminish.
PVCS stenosis increases

MANEUVERS THAT INCREASE MURMUR INTENSITY

Maneuvers
Interpretation
Inspiration
Right-sided
Valsalva
HCM
Squat to stand
HCM
Handgrip
Mitral regurgitation, VSD
Transient arterial occlusion
Mitral regurgitation, VSD
MANEUVERS THAT RESULT IN DECREASED MURMUR INTENSITY
Maneuvers
Stand To Squat
Leg elevation
Handgrip

Interpretation
HCM
HCM
HCM

Believe that you can and youre halfway there

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Cardiology: Physical Examination of the Cardiovascular System

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