Download Session 10: The Stethoscope and Beyond: Cardiac Diagnoses Not

Session 10:
The Stethoscope and Beyond:
Cardiac Diagnoses Not to Be Missed
Learning Objectives
1. Incorporate the most identifiable physical findings, patient history, and
additional tests as needed to determine the etiology of abnormal heart sounds
detected via auscultation.
2. Distinguish between benign heart sounds and those requiring prompt work-up
and intervention.
Session 10
The Stethoscope and Beyond: Cardiac Diagnoses Not to Be Missed
Faculty
Richard F. Wright, MD, FACC
President, Research Director, and Director
Heart Failure Center
Pacific Heart Institute
Santa Monica, California
Dr Richard Wright is president, research director, and director of the Heart Failure Center at the Pacific Heart Institute
in Santa Monica. He previously served as director of the Heart Institute and Cardiac Critical Care at Saint John’s Health
Center, also in Santa Monica, and on the clinical faculty at the University of California, Los Angeles (UCLA).
Dr Wright earned his medical degree from Harvard Medical School and completed his medical residency and cardiology
fellowships at Boston’s Brigham and Women’s Hospital.
Dr Wright is currently co-director of the California Medicare Contractor Advisory Committee, chair of the American
College of Cardiology (ACC) National Carrier Advisory Committee, and cardiology advisor to the Relative Value Update
Committee of the American Medical Association. A past president of the ACC’s California chapter. Dr Wright has even
served on the medical advisory board of the Los Angeles Zoo, where he was veterinarian cardiologist for the great apes.
Dr Wright is a renowned lecturer on cardiovascular topics and was a co-author of the U.S. guidelines on management of
patients with heart failure. A recipient of the Specialist of the Year Award from the ACC, he continues to be listed in
peer surveys as one of the top cardiologists in California.
Faculty Financial Disclosure Statement
The presenting faculty reports the following:
Dr Wright has no financial relationships to disclose.
Disclosures
• Dr Wright has no financial relationships to disclose.
Session 10: 1:15 PM - 2:15 PM
The Stethoscope and Beyond:
Cardiac Diagnoses Not to Be Missed
A Case-Based Approach
Richard F. Wright, MD, FACC
2
Learning Objectives
Outline - Practical Implications
for Primary Care
• Incorporate the most identifiable physical findings, patient
history, and additional tests as needed to determine the
etiology of abnormal heart sounds detected via
auscultation
Cardiovascular Case Presentation
• Use of your eyes
• Use of your hands
• Distinguish between benign heart sounds and those
requiring prompt work-up and intervention
• Use of your ears… the stethoscope
Diagnoses not to be missed
Case 1: 23-year-old woman
Case 1: 23-year-old woman, cont’d
• She complains of recent palpitations
• No personal history of any cardiac problem, murmur, or
childhood illness
• Physically very active
– No dyspnea, chest discomfort, or exercise impairment
• Current medications: birth control pills
– Competitive athlete: volleyball
• No family history of cardiac issues
• Aware of an occasional “flop” in her chest when she is
lying in bed
– No faintness, tachycardia, or syncope
1
Case 1: 23-year-old woman, cont’d
Case 1: Pre-Question 1
• Physical exam
In this patient, what is a likely provisional diagnosis?
– Wt 132 lbs, Height 72”
– BP 112/50 mmHg in both arms; pulse regular, 58/min
1. Anxiety
– I/VI decrescendo diastolic murmur at the left sternal
border
2. Hypertrophic cardiomyopathy
• Labs (at a recent gynecological exam): normal
3. Mitral valve prolapse and regurgitation
• ECG today: normal
4. Dilated ascending aortic root
5. Rheumatic heart disease
Case 2: 81-year-old man
Case 2: 81-year-old man, cont’d
• Complains of exertional dyspnea
PMH
• Has gradually limited his exercise over the last 6 months
due to shortness of breath
• 10-year history of hypertension
• Borderline hypercholesterolemia
– No chest discomfort
• Hyperuricemia
– No palpitations or syncope
– Possible mild ankle edema recently noted
Current medications
– No history of any cardiac problem
• amlodipine/benazepril 5/20 mg daily
• Allopurinol 300 mg daily
• Vitamin D 1,000 iu daily
Case 2: 81-year-old man, cont’d
Case 2: 81-year-old man, cont’d
• Physical exam
– Wt 165 lbs, Height 69”
– BP 139/60 mmHg; pulse regular, 73/min
– III/VI harsh systolic murmur over the precordium,
radiating to neck… increases with bearing down
– Jugular pressure 6 cm
– Mild hepato-jugular reflux
– Trace pedal edema
• Labs: Normal
• ECG: LVH with very deep T wave inversions
2
Cardiovascular Exam
Case 2: Pre-Question 1
Use your:
In this patient, what is the most likely diagnosis?
¾ Eyes
1. Coronary artery disease and prior infarction
2. Hypertensive heart disease with diastolic heart failure
¾ Hands
3. Significant mitral regurgitation
¾ Ears
4. Calcific aortic stenosis
5. Hypertrophic cardiomyopathy
¾… and Brain
14
Cardiovascular Exam: Using Your Eyes
Cardiovascular Exam: Using Your Eyes
• Appearance of the patient
Appearance of the Patient
• Carotid artery impulse
• ? Tall
• Jugular venous height
• ? Unusually short
• ? “Marfanoid”
• Jugular venous contour
• ? Cyanotic
• Chest wall cardiac impulse
• ? Abnormal palate
• ? Chest wall deformed
Appearance of the Patient
Cardiovascular Exam: Using Your Eyes
Carotid artery impulse:
Picture courtesy of the National Marfan Foundation
3
•
One upstroke… rapid
•
Does not vary with breathing
•
No change with abdominal pressure
•
No change with the “Valsalva maneuver”
Cardiovascular Exam: Using Your Eyes
Cardiovascular Exam: Using Your Eyes
Jugular veins:
Jugular veins:
•
An undulatory rhythmic pattern
• Normal height is less than 5 cm…
•
In normal rhythm, two waves visible
• Falls with normal inspiration
•
In atrial arrhythmia, multiple waves often visible
•
External jugular veins can be used…
• Increases with increased thoracic pressure (eg,
Valsalva maneuver)
• In abnormal hearts, increases with abdominal pressure
(eg, “hepato-jugular reflux”)
…but venous valves or neck muscles can interfere
Cardiovascular Exam: Using Your Hands
Cardiovascular Exam: Using Your Ears….
• Shake the patient’s hand…
• Carotid artery impulse: a rapid “tap”
• Chest wall deformation
… the Stethoscope
• Chest wall tenderness
• Precordial palpation
• Liver size and pulsation
• Abdominal aorta size
• Peripheral pulses
Cardiovascular Exam: Using Your Ears…
…the Stethoscope
Cardiovascular Exam: Using Your Ears…
…the Stethoscope
• Acoustic?
• Acoustic?
• Electronic?
Not important…
• Bell? Diaphragm?
• Short or long tubing?
• Electronic?
• Bell? Diaphragm?
• Short or long tubing?
4
Cardiovascular Exam: Using Your Ears…
…the Stethoscope
Case 1: 23-year-old woman with
palpitations …revisited
IMPORTANT:
• Physical exam
– Wt 132 lbs, Height 72”
¾ Know what to listen for…
– BP 112/50 in both arms; pulse regular, 58/min
¾ Know how to integrate those sounds with that patient…
– I/VI decrescendo diastolic murmur at the left sternal
border
¾ Practice makes perfect…
– Long fingers
Case 1: Post-Question 1
Case 1: Question 2
In this patient, what is a likely provisional diagnosis?
In this patient, what would you recommend as the next
diagnostic test, if any?
1. Anxiety
2. Hypertrophic cardiomyopathy
1. No further testing is warranted at present
3. Mitral valve prolapse and regurgitation
2. Echocardiography
4. Dilated ascending aortic root
3. Magnetic resonance angiography (MRA)
5. Rheumatic heart disease
4. CT angiography of the pulmonary artery
5. Genetic testing
Case 2: 81-year old-man with dyspnea,
revisited…
Case 2: Post-Question 1
• Physical exam
In this patient, what is the most likely diagnosis?
– III/VI harsh systolic murmur over the precordium,
radiating to neck… increases with bearing down
1. Coronary artery disease and prior infarction
– Jugular pressure 6 cm
2. Hypertensive heart disease with diastolic heart failure
– Mild hepato-jugular reflux
3. Significant mitral regurgitation
– Trace pedal edema
4. Calcific aortic stenosis
5. Hypertrophic cardiomyopathy
5
Cardiovascular Exam
Using Your Hands, Eyes, and Ears
Case 2: Question 2
In this patient, what would you recommend as the next
diagnostic test, if any?
9 Still very important – even in our high-tech era
9 Very cost effective
1. No further testing is warranted at present
9 Allows easy follow-up over time
2. Echocardiography
9 …But it does take experience
3. Treadmill stress test
4. CT angiography of the coronary arteries
5. Cardiac catheterization
Questions
?
6