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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