Download AUSCULTATION SKILLS for ATHLETIC TRAINERS

AUSCULTATION SKILLS for ATHLETIC TRAINERS
Dennis A. Cardone, DO, CAQSM
Director, Sports Medicine and Sports Medicine Fellowship
UMDNJ-Robert Wood Johnson Medical School
New Brunswick, NJ
The Athletes Heart (Athletic Heart Syndrome)
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History
a. Dietlen 1908: excessive and continued strain could lead to collapse of the cardiovascular
system
b. Medical community early 1900s: increased cardiac size in athletes was a pathologic
response to the increased cardiac stress of exercise
c. Frieberg 1972: cardiovascular changes noted among athletes were more a function of
disease (acquired or congenital) than a physiologic response to the adaptations caused by
the athlete’s training
d. 2004: athletic heart syndrome represents normal physiologic adaptations to training that
allows normal or improved cardiac function in contrast to the cardiac dysfunction of
pathologic hypertrophy.
Physiologic response of cardiovascular system to exercise
a. Exercise training
i. Peripheral response
1. increased number of capillaries, mitochondria, oxidative enzymes
2. improved uptake and utilization of O2 in skeletal muscles
ii. Central response (Heart adaptations)
1. increased stroke volume due to cardiac dilation and hypertrophy
2. decrease in resting HR (CO=SV x HR)
3. maximal HRs are same in trained and untrained athletes
4. increased vagal tone
History: negative
Physical examination
a. Bradycardia
b. Lower BP
c. Laterally displaced PMI (because of LVH)
d. Auscultation
i. Systolic ejection murmur (most intense supine b/c increased left ventricular
filling; less intense standing or squatting b/c decreased left ventricular
filling)
ii. Sinus arrhythmia
iii. Wide splitting first heart sound
iv. Wide splitting second heart sound
v. Filling sounds – S3 ventricular gallop
vi. Venous hums
vii. Systolic bruits over carotid arteries
viii. Other innocent systolic murmurs
ix. Diastolic murmurs are not associated with AHS
EKG findings
a. Bradycardia
b. Sinus arrhythmia
c. First-degree heart block (prolonged PR interval)
d. Second-degree heart block (Wenckebach’s block, a sequential prolongation of PR
interval with eventual dropped beat)
e. Junctional rhythms
f. Right axis deviation
VI.
VII.
g. Incomplete RBBB
h. LVH
i. Minor ST-T wave changes
j. Resolve with exercise
Echocardiography
a. Increased left ventricular wall thickness
b. Increased left ventricle chamber size
c. Right ventricle and left atrium size may be increased
How much exercise to achieve anatomic and physiologic changes?
a. Dynamic exercise
b. 30-60 minutes
c. 3-4 times per week
d. 60-70% VO2 max
CARDIAC AUSCULTATION
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VI.
Examine in different positions
a. Sitting
b. Supine
c. Left lateral recumbent
d. Standing
e. Squatting
Stethoscope
a. Bell: low-frequency sounds
b. Diaphragm: high-frequency sounds
Sites for auscultation
a. Lower left lateral sternal border (4th ICS): tricuspid valve and right side of heart
b. Apex (5th ICS midclavicular line): mitral valve and left side of heart
c. Right base (2nd ICS): aortic valve
d. Left base (2nd ICS): pulmonic valve
Sequence of auscultation
Classification of sounds and murmurs
a. I: very faint, heard after listener tunes in
b. II: heard immediately but faint
c. III: loud but without a thrust or thrill
d. IV: loud with a thrust or thrill
e. V: loud with a thrust or thrill and heard with chestpiece tilted on chest
f. VI: loud with thrust or thrill and heard with chestpiece just off chest wall
Cardiac sound-cycle relationship
a. First Heart Sound - S1
i. Beginning of ventricular systole
ii. Closure of mitral and tricuspid valves
iii. Split S1
b. Second Heart Sound – S2
i. Ventricular diastole
ii. Closure of aortic and pulmonic valves
iii. Split S2 usually heard on inspiration
c. Fourth Heart Sound – S4
i. Diastolic sound heard just before S1
ii. Low frequency
iii. Result of decreased ventricular compliance or increased volume of filling
iv. Sign of ventricular stress
1. normal in athletes <20 years (increased diastolic volume)
2. severe HTN, aortic stenosis, CAD, Cardiomyopathy, pulmonary stenosis
d. Third Heart Sound – S3
i.
ii.
iii.
iv.
e.
f.
g.
h.
Diastolic sound that occurs during early rapid filling of ventricles
Low frequency
Heard just after S2
Result of decreased ventricular compliance or increased ventricular diastolic volume
1. Normal in children and young adults
2. May be heard in athletes over 40 years
3. Pathologic conditions: CHF, CAD, Cardiomyopathy
Murmurs
i. Sustained noises audible during the time periods of systole, diastole, or both
ii. Frequency: high, medium, low
iii. Quality: blowing, harsh or rough, rumble
iv. Timing
1. Systolic murmur: occurs between S1 and S2
2. Diastolic murmur: occurs between S2 and S1
Systolic murmurs
i. May be normal in athletes (increased blood flow)
ii. Produced from forward blood flow across aortic or pulmonic valves or regurgitant
flow from mitral or tricuspid valve
iii. Valves may be normal (but high rate of flow) or abnormal
iv. Pathologic conditions: mitral insufficiency, aortic stenosis, pulmonic stenosis
v. Early systolic murmurs
1. “innocent” murmurs
2. incompetent valve
vi. Midsystolic murmurs
1. aortic or pulmonic stenosis
vii. Late systolic murmurs
1. MVP
viii. Pansystolic murmurs
1. Begins with S1 and ends with S2
2. mitral or tricuspid regurgitation, VSD
Diastolic murmurs
i. Not normal are PATHOLOGIC
ii. Mechanisms:
1. aortic or pulmonic valve incompetence
2. mitral or tricuspid stenosis
3. increased blood flow across mitral or tricuspid valves
iii. Early diastolic murmurs
1. aortic regurgitation
2. pulmonic regurgitation
iv. Mid-diastolic murmurs
1. mitral stenosis
2. tricuspid stenosis
v. Late diastolic murmurs
1. S1 is difficult to hear
2. mitral or tricuspid stenosis
vi. Pandiastolic murmurs
1. S2 and S1 are difficult to hear
2. PDA
Sounds around S1
i. Wide split S1
1. RBBB, ventricular tachycardia, third degree heart block
2. mitral stenosis
ii. Ejection sounds
1. High frequency “clicking” sounds that occur shortly after S1
2. Aortic or pulmonic origin
a. Pulmonic stenosis
VII.
b. Valvular aortic stenosis
c. Aortic insufficiency
iii. Mid-systolic clicks
1. Usually occurs in middle of systole
2. MVP
i. Sounds around S2
i. Paradoxical split S2
1. Closure of aortic valve is delayed
2. Severe aortic stenosis, severe aortic regurgitation
ii. Wide split S2
1. Abnormal delay in pulmonic valve closure
2. ASD, VSD, pulmonary stenosis
iii. Fixed split S2
1. Split doesn’t change with respiration
2. CHF, Cardiomyopathy, ASD, VSD
iv. Narrow split S2
v. Opening snap
1. Opening of mitral valve
2. Occurs after S2
3. Mitral stenosis
j. Friction rubs
i. Pericardial inflammation: sound is a scratching, grating, or squeaking
ii. Pleural inflammation: disappears if breath is held
k. Common adult abnormalities
i. Mitral regurgitation and tricuspid regurgitation
1. Systolic murmur
2. Wide split second sound
3. S3 if CHF present
ii. Aortic stenosis
1. Aortic ejection sound
2. Systolic ejection murmur
3. Normal split S1
4. Physiologic split S2
iii. Pulmonic stenosis
1. Pulmonic ejection sound
2. Systolic ejection murmur
iv. Aortic regurgitation
1. Aortic ejection sound
2. Early diastolic murmur
v. Pulmonic regurgitation
1. Pulmonic ejection sound
2. Early diastolic murmur
vi. Mitral stenosis and tricuspid stenosis
1. Louder than normal S1
2. Opening snap after S2
3. Mid-diastolic ejection murmur
4. Late diastolic accentuation of murmur
l. Pediatric systolic murmurs
i. Innocent murmurs
1. Still’s murmur
2. physiologic systolic ejection murmur
3. arterial supraclavicular bruit
4. pulmonary flow murmur
5. cervical venous hum
When to refer
a. 6-90% of school age children have innocent murmurs
b.
VIII.
Innocent murmurs
i. Normal history
ii. Never solely diastolic
iii. Area of maximal intensity well localized
iv. Grade is less than III/VI
v. Innocent systolic murmur decreases with standing
c. Refer if:
i. Murmur grade III/VI or higher
ii. Harsh murmur
iii. Diastolic murmur
iv. Pansystolic murmur
v. Diffuse area of maximal intensity
vi. Murmur radiates to back or neck
vii. Pathological murmur increases with standing or valsalva
World Wide Web Links
a. www.music.mcgill.ca/auscultation/the_heart.html
b. http://medicine.osu.edu/exam/
c. www.medinfo.ufl.edu/year1/bcs/clist/cardio.html
d. www.med.ucla.edu/wilkes/inex.htm