Download Cardiac Ausculation in the Elderly

2007 대한임상노인의학회 추계학술대회
Cardiac Ausculation in the Elderly
박 성 하
신촌세브란스병원 심장혈관병원 심장내과
Evaluating pulsation
Anatomy
„
Surface projection of the Heart and Great Vessels
Superior vena cava
Rt. pulmonary artery
Right atrium
Right ventricle
Aorta
Lt. pulmonary artery
Pulmonary artery
Left ventricle
Apical impulse
femoral
carotid
Dorsalis pedis
Post. tibial
Arterial Pulse
Arterial Pulse
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2007 대한임상노인의학회 추계학술대회
Auscultation
Palpation – Thrill
„
Systolic thrill
- AS: Rt 2nd, 3RD ICS, suprasternal notch, jugular
Maximal intensity
- VSD: Lt 4th, 5th ICS
and radiation of
- PS, ASD: Lt 2nd ICS
„
- MR: apex to left axilla
six isolated sys.
Diastolic thrill
murmurs
- MS: apex
- AR, Ascending aorta dissection: Rt parasternal border
„
Continuous thrill
- PDA
- AV fistula
HighHigh- and LowLow-frequency Sounds Explained
Auscultation
Cardiac apex
Mid-sternal edge
Left lateral decubitus
position
Leans forward with breath
held in full respiration
Timing of Cardiac Sounds
Physiology
• Events in Cardiac Cycle
S1(first heart sound) : MV closure
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박성하: Cardiac Ausculation in the Elderly
Physiology
• Events in Cardiac Cycle
Ej (ejection sound)
Physiology
• Events in Cardiac Cycle
: AV opening
S2 (second heart sound) : AV closure
Physiology
Physiology
• Events in Cardiac Cycle
OS (Opening snap) : MV opening
• Events in Cardiac Cycle
S3 (third heart sound) : LA Î LV diastolic filling
Physiology
Auscultation
• Events in Cardiac Cycle
Rate & regularity
„ Heart sounds – especially intensity
and quality of S2, as well as extra
sounds (S3, S4)
„ Murmurs
„ Clicks
„ Rubs
„
S4 (fourth heart sound) : Atrial contraction
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2007 대한임상노인의학회 추계학술대회
Systolic Murmur -
Intensity of murmurs
ejection vs regurgitant
„
I
„ II
„ III
„ IV
„V
„
„
VI
barely audible
Regurgitant: Pansystolic murmur
occurs with S1
Soft, but easily audible
MR
Moderately loud
S1
Louder, with a thrill
„
Audible with stethoscope
barely on chest
S1
AS
Audible with stethoscope off chest
S1
Systolic Murmurs
S2
Ejection: Mid-systolic murmur
occurs after S1
S2
S1
Selected causes of systolic murmur
„
1.
2.
3.
4.
5.
6.
7.
8.
Abnormal cardiac structure
Aortic stenosis
Hypertrophic cardiomyopathy
Mitral regurgitation
Mitral valve prolapse
Ventricular septal defect
Pulmonic stenosis
Tricuspid regurgitation
Atrial septal defect
„
1.
2.
3.
4.
Normal cardiac structure, increased flow
Anemia
Thyrotoxicosis
Sepsis
Renal failure with volume overload
How to rule out pathologic systolic murmur
„Prevalence of systolic murmur in
unreferred young adults: 5-52%
„Prevalence of systolic murmur in the
elderly: 29-60%
„Prevalence of systolic murmur in
pregnancy: 90-94%
„Prevalence of valvular heart disease in
patients referred for murmurs: < 50%
„98% of patients < 50 years of age with
systolic m ≤ grade 2/6 had innocent
murmurs
„> 2/6 grade systolic m and abnormal EKG
are independent predictors of significant
valvular heart disease in 224 consecutive
patients with systolic murmur
Movahed MR et al. Echocardiography 2007;24:447-451
Etchells E et al. JAMA 1997;277:564-571
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Reichlin S et al. Am J Emerg Med 2004;22:71-75
박성하: Cardiac Ausculation in the Elderly
Criteria of pathologic murmur
Aortic stenosis
„> 2/6 grade systolic murmur with maximal
intensity at RUSB 2nd ICS
„Abnormal EKG
„Murmur or thrill over right carotid, clavicular
area
„Prolonged, blunted cardiac upstroke
„Soft or absent S2
Ejection: Mid-systolic murmur
occurs after S1
AS
S1
Das P et al. Q J Med 2000;93:685-688
Integrating pulse with
sounds and murmur
Hemodynamics
and flow
Inspection:
Pressures:
„ Carotid pulse for timing
„ LV-Ao pressure gradient
throughout systole
– murmur occurs w/ upstroke
–
–
–
–
murmur occurs w/ upstroke
sound occurs near peak
murmur is systolic
sound is S2
CW Doppler:
„ high velocity outflow
– reaches peak of 5 m/sec
– est. 100 mmHg gradient
„ Compare with normal carotid
– normal peaks well before S2
– carotid peak is delayed
– carotid peak is weak
Severe AS:
„ LV pressure rises
– increases LV-Ao gradient
„ murmur peaks later
Auscultation:
„ murmur is midsystolic
„ murmur ends before S2
„ Ejection sound at 3RICS
Chronic MR
Mitral regurgitation
Inspection:
„ apex beat displaced to 7LICS
„ outward excursion of
stethoscope head during
systole
Auscultation:
„ blowing murmur with outward
excursion of stethoscope
„ a thudding sound with inward
return of stethoscope
Regurgitant: Pansystolic murmur
occurs with S1
„ murmur is holosystolic
– heard best over LV
MR
„ sound is S3
S1
S2
S1
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S2
S1
2007 대한임상노인의학회 추계학술대회
Acute MR
Patient 07
Inspection:
„rocking stethoscope by
LV
„left subcostal heave (RV)
Auscultation:
„Early systolic murmur
begins with sharp S1
„Isolated, clear S2
„S3 rumble
Mitral valve prolapse
Hemodynamics of
Acute and Chronic
Normal:
„S1, S2, no murmurs
Mitral valve prolapse:
„midsystolic click, possible late
systolic murmur of MR
Acute MR:
„here, from chordal rupture
„loud S1, initiates explosive
systolic murmur
„S3 with mid-diastolic murmur
MVP
Compensation:
S1 click S2
S1
„increased compliance of LA,
LV
„blowing holosystolic murmur
„mid-diastolic rumble
Ventricular Septal defect
Tricuspid regurgitation
Variation of pansystolic murmur according to respiration
(Carvallo’s sign)
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박성하: Cardiac Ausculation in the Elderly
Diastolic Murmurs
Diastolic Murmur –
Early and mid.
„Rumbling murmur :
MS
S2
S1
S1
„Early-diastolic murmur :
AR
S2
S1
S1
Mitral Stenosis
Mitral stenosis
Inspection:
„ subtle monophasic pulses in
suprasternal notch (carotid)
„ conspicuous biphasic pulses
(JVP), are a-wave dominant
„ stethoscope displays RV lift
during systole
Auscultation:
MS
„ loud S1 (coincides w/ a-wave)
S1
Patient 05
S2
OS
S1
„ “split” S2 is fixed
– S2
– opening snap (OS)
Compare sounds
with split S2, S3
Listening at Base:
„ abnormally loud S1 at base
„ shorter S2-OS interval
indicates
severe MS
Listening at Apex:
„ crescendo, presystolic
murmur
„ loud S1
„ S2, OS
„ mid-diastolic murmur
Inspection:
„ JVP is a-wave dominant
„ a-wave occurs with loud S1
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2007 대한임상노인의학회 추계학술대회
Add / Remove sounds
Hemodynamic effects
of heart rate
80 bpm:
Loud S1:
„ tachycardia exacerbates LA
emptying dysfunction
„ loud S1
„ loud MDM, PSM
„ elevated LA pressure
„ mitral valve closes later, and
more loudly than normal
Opening Snap:
110 bpm:
„ mitral valve opens earlier than
normal ( LA pressure)
„ fused leaflets abruptly halt
mitral valve opening, causing
OS
„ loud murmur was thought to
be
systolic by house staff
„ murmur ends with loud S1
„ mid-diastolic murmur
66 bpm:
„ each component can be
heard
„ loud S1, S2/OS, MDM, PSM
Mid-diastolic murmur:
„ corresponds w/ LA-LV
gradient
Acute severe,
rapid heart rate
Aortic Regurgitation
Examination at 3LICS
„ bounding (Corrigan's) pulse
„ to-fro systolic & diastolic
murmur
– harsh midsystolic murmur
– abbreviated early diastolic
murmur initiated by a loud S2
Inspection of nailbed
„ light compression of fingernail
„ blanching & blushing of
nailbed
AR
S1
Patient 02
S2
S1
Well-tolerated aortic
regurgitation
Inspection:
„ Carotid pulse
– visible at suprasternal notch
– normal upstroke
– upstroke occurs near S1
„ Jugular venous pulse
– visible at right supraclavicular
fossa
– biphasic
– displaces neck chain
Auscultation:
„ EDM is long (holodiastolic)
„ sounds like whispered “R”
„ longer murmur = better
tolerated
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Chronic vs. Acute
Aortic Regurgitation
Aortic Regurgitation
Inspection:
Chronic:
„ bounding (Corrigan’s) pulse
„ at Base:
– MSM (Ao outflow)
– EDM (Ao regurgitation)
„ head bobbing (Musset’s sign)
„ compare with normal carotid
„ at Apex:
– Austin Flint (mitral inflow)
– “split” S1 (S1 + ejection sound)
Auscultation:
„ “To-fro” murmur
Acute:
– Midsystolic murmur
– Early diastolic murmur
„ at Base:
– MSM (Ao outflow)
– EDM is abbreviated
„ 3RICS
– “To-FRO”
„ at Apex:
– Austin Flint (mitral inflow)
– absent S1 (ejection sound
only)
„ 2RICS
– “TO-fro”
Third Heart Sound S3
Physiology
• Events in Cardiac Cycle
S3 (third heart sound) : LA Î LV diastolic filling
Fourth Heart Sound S4 Gallop
Physiology
• Events in Cardiac Cycle
S4 (fourth heart sound) : Atrial contraction
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2007 대한임상노인의학회 추계학술대회
Splitting of the Second Sound
S3 and S4
Associated with abnormal S3,S4: Summation gallop
Fixed S2 splitting with respiration
Inspiration
Atrial septal defect
Expiration
Venous return
Venous return
S1
S1
A2 P2
A2 P2
Inspiration
Venous return
In ASD
LÆR shunt
Fixed S2 split!!
Expiration
LÆR shunt
Venous return
Mid systolic murmur and S2 split at 2nd pulmonic area
Diastolic murmur:
Austin Flint
Listening at apex:
„ tachycardia (110 bpm)
„ dynamic, displaced apical
impulse
„ absence of S1
„ triple cadence consisting of
– midsystolic murmur
– S2 initiating a brief early
diastolic murmur
– mid-diastolic murmur
superimposed on the early
diastolic murmur, (to-froFRO)
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박성하: Cardiac Ausculation in the Elderly
Summary of Heart Sounds & Murmurs
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