Terminology Problems

What are the differences between cardiac hypertrophy, dilatation, enlargement, and overload ANS The term hypertrophy refers to the thickening of the ventricular chambers. Dilatation refers to an increase in chamber volume. The terms enlargement and overload are not specific because they refer to either hypertrophy and or dilatation. However, enlargement tends to be used as a synonym for dilatation. Pure LVH causes an encroachment inward on the cavity and has been called concentric hypertrophy....

Timing

Which left ventricular (LV) hemodynamic events occur in diastole after the S2 but before the S3 ANS Isovolumic relaxation, and after opening of the mitral valve, early rapid filling of the LV. 2. When does isovolumic relaxation begin and end in the LV ANS It begins with aortic valve closure and ends with mitral valve opening. As soon as isovolumic relaxation ends and the mitral valve opens, the LV fills rapidly from the left atrium. Between point A (aortic valve closure) and point B (mitral...

Quantitating the Degree of Mitral Regurgitation

How can you tell the degree of MR by palpation a. The larger the LV by palpation. b. The greater and later the left parasternal movement. (This may represent the left atrium expanding during systole.) c. The more palpable an early rapid filling wave and S3 at the apex. 2. How can you tell the degree of MR by auscultation a. The louder and longer the apical systolic murmur. However, although ruptured chordae murmurs may be decrescendo, they are almost always at least grade 3 6 in loudness 4 . b....

Definitions and Terminology

What is meant by a ballooned or prolapsed mitral valve What auscultatory findings does it cause ANS This term refers to the bulging or buckling of one or both mitral valve leaflets into the left atrium during systole, so that one or more crisp systolic sounds or clicks and a late systolic MR murmur are commonly heard. The systolic murmur usually goes to the A2. There may be only a click, only a murmur, or both. 2. How common are prolapsed mitral valves in asymptomatic subjects ANS About 2 of...

The Bell Chest Piece

What is the relation between the tautness (stiffness) of a membrane that collects sound from the chest wall and the ability of the membrane to transmit high or low frequencies ANS The tauter the membrane, the higher is its natural frequency of oscillation and the more efficient it is at higher frequencies. Note The terms frequency and pitch are usually used interchangeably. However, frequency refers to the number of oscillations per second made by a sound-producing structure, while pitch is...

Physical Causes

ANS Sufficient flow in the cardiovascular system to generate enough turbulent energy in the walls of the heart or blood vessels to produce sounds. High-energy turbulence can be produced by either obstruction to blood flow or flow into a distal chamber of larger diameter than the proximal one. Causes of turbulence. In A, turbulence occurs in fluids flowing at high velocity through tubes of uniform caliber, according to the formula for Reynolds numbers. In B and C, either a local obstruction or...

Chest Position to Find the Apex Beat

Why is the sitting position with the feet on the bed the best position to establish the site of the normal apex beat ANS It is the most compatible compromise with the familiar normal apex site on a chest X-ray. Also, in the sitting position the apex beat often becomes more palpable than it does even standing, because with the legs on the bed the upward compression by the abdominal contents and diaphragm shifts the apex beat slightly to the left against the chest wall. 2. Does the apex beat move...

PDA Murmur Shape and Duration

What are some of the other names for the continuous murmur of a PDA when it is truly continuous ANS A machinery or a Gibson murmur. 2. Why is a PDA murmur continuous ANS Because there is a continuous aortic-pulmonary pressure gradient throughout both systole and diastole (if the pulmonary artery pressure is not far from normal). 3. When is the continuous murmur of PDA not machinery in quality or duration ANS When it is not truly continuous, i.e., when it begins slightly after the S1, crescendos...

On Leftsided Regurgitant Murmurs

What will happen to the loudness of a left-sided regurgitant murmur, such as that heard in mitral regurgitation (MR) or VSD, after a sudden long diastole ANS The loudness usually remains about the same. (Listening for the effect of a sudden long diastole is one of best ways to differentiate an ejection from a regurgitant murmur.) A high- and medium-frequency phonocardiogram taken at the apex together with an external carotid tracing from a 45-year-old woman with moderately severe chronic...

Raising Peripheral Resistance or Blood Volume

What happens to left-sided regurgitant murmurs if the peripheral resistance is increased Why ANS They become louder, because with regurgitation there are two outlets for systole, and an increased resistance at the aortic outlet promotes more outflow through the regurgitant outlet. 2. How will raising the blood pressure with handgrip, squatting, or phenylephrine help you to determine whether a long systolic murmur at the apex is due to AS or MR ANS With increased peripheral resistance, aortic...

Venous Pressure By Jugular Inspection

With which chambers of the heart are the jugular veins in continuity in systole and in diastole ANS In systole the jugular veins are in continuity only with the right atrium, because the tricuspid valve is closed. In diastole, when the tricuspid valve is open, the jugulars are also in continuity with the right ventricle (RV). Therefore, examination of the jugulars may reveal the contour and pressure in the right atrium and RV without the need for catheterization. In diastole, the atrium and...

Murmurs with High Pressure in the Pulmonary Artery Graham Steell Murmur

How high does the pulmonary artery pressure have to be to produce a pulmonary regurgitation (PR) murmur ANS It is usually at nearly systemic levels. Pulmonary regurgitation murmurs are rarely present with pulmonary artery pressures of below 80 mmHg systolic unless the main pulmonary artery is markedly dilated. Note A Graham Steell murmur is a PR murmur that is secondary to pulmonary hypertension. 2. How does the Graham Steell murmur differ from the AR murmur ANS It may not differ, i.e., both...

MtAt OR MtTt

What is the difference in quality between an S4 and the first major component of a split S1, i.e., the M1 ANS When the S4 is loud, it is difficult to tell the difference in quality between an S4 and an M1, but when soft, the S4 has fewer high frequencies, so that it is often inaudible when the diaphragm is pressed hard against the chest. The M1 is usually heard almost as well with the diaphragm as with the bell, regardless of whether it is loud or soft. The use of a diaphragm will eliminate...

Abdominal Aortic Aneurysm

Which patients should be routinely screened for AAA ANS Patients with increased risk, especially those over age 50 with hypertension or coronary disease history. 2. How can palpation be used to screen for AAA ANS Note the separation of the index fingers with each systole with the hands placed on each side of the aorta. If the pulsating area is more than 2.5 cm in width after allowing for skin thickness, a pulsatile mass should be considered to be present. (Abdominal or femoral bruits are of no...

Loudness And Audibility Of The S4

Where is the LV S4 usually best heard ANS At the apex, when the patient is in the left lateral decubitus position. 2. Why should you usually use the stethoscope bell to bring out the S4 ANS An S3 or an S4 may occasionally be heard better with firm bell pressure, which reduces the volume inside the bell. It may be that the volume displacement by the A wave into a smaller total volume produces a greater effect on the eardrum. 3. Why is held expiration as a means of bringing the stethoscope closer...

The S4s1 Interval And Severity Of Dysfunction

What is the relationship between the S4-Sj interval and the severity of the loss of compliance present ANS The shorter the P-S4 interval the more severe is the loss of compliance 6 . This means that the longer the S4-S1 interval, the more severe is the loss of compliance. The longer the S4-Sj interval, the greater is the loss of compliance of the LV (provided the P-R interval is not prolonged) and usually the louder is the S4. The longer the S4-Sj interval, the greater is the loss of compliance...

Pericarditis

What is the mechanism that causes friction rubs ANS It is usually assumed that the rub sounds are caused by the two roughened pericardial membranes (the visceral and parietal pericardia) sliding over each other. However, when the overlying pleura is also involved, perhaps the noises are caused by the pleura rubbing against the outer layer of pericardium. The rub then would be a pleuropericardial friction rub. This murmur of primary PR in a teen-age boy was early diastolic and had many low and...

Terminology

Why may it be preferable to use the term mitral regurgitation rather than mitral incompetence or mitral insufficiency, even though cardiologists are about equally divided as to the preferred usage ANS The abbreviation for mitral incompetence or insufficiency is MI, which is also used as an abbreviation for myocardial infarction. There is no confusion when MR is used. Note Regurgitation describes the direction of the flow, whereas incompetence or insufficiency describes the condition of the...

The Jugulars in Atrial Fibrillation AF

Why will AF attenuate the X' descent and cause a dominant Y descent ANS In AF the RV contraction is decreased due to a lack of a booster pump effect of atrial contraction at the end of diastole. 2. Why will a patient in AF with congestive heart failure often have no X' descent at all, i.e., only a Y descent may be seen ANS a. The decrease in RV contraction due to the decreased venous return causes a decreased descent of the base. The wave before the X' cannot be an A wave since it is not due to...

The Normal Site of an Apex Beat

What is the disadvantage of using the midclavicular line as the site of the normal apex beat in the sitting position (with the feet on the bed) ANS a. Some medical dictionaries equate the midclavicular line with the nipple line to which it may bear no relation. b. The lateral end of the clavicle is often difficult to locate accurately. 2. What is an easier, more accurate method of finding the site of an apex beat in order to diagnose cardiomegaly ANS With the patient sitting up in bed with the...

Differences Between the A2P2 and the 2OS

When is an OS louder or as loud at the apex as it is at the left sternal border ANS As a rule, this occurs only when the LV is dilated, or if a rib has been removed in previous heart surgery. A P2 is never as loud or louder at the apex than at the left sternal border. If the second component of a split S2 is louder or as loud at the apex as at the left sternal border, it is probably an OS. 2. How does the effect of respiration affect the loudness of the P2 differently from that of the OS ANS...

The Pathological S3

What are the most common associated cardiac findings with a pathological S3 ANS A high mean left atrial pressure due to a high V wave, a noncompliant LV, and a large ventricle resulting from a poor ejection fraction. 2. What pathological cardiac condition is generally present when an S3 occurs in the presence of a high left atrial pressure due to a low ejection fraction ANS A cardiomyopathy, most often idiopathic (which is probably viral) or due to extensive ischemic heart disease. Note In...

The Tricuspid Opening Snap

When will a tricuspid OS be present in the absence of tricuspid stenosis (TS) ANS a. When a large volume enters the RV by way of the tricuspid valve as with an ASD or anomalous pulmonary venous drainage into the right atrium 2 . b. With a deformed tricuspid valve, as in the Ebstein anomaly. 2. How does the effect of respiration on the mitral and tricuspid opening snaps differ ANS A tricuspid OS becomes louder on inspiration because more blood flows through the tricuspid valve on inspiration.

The PR Interval and Ml Loudness

Why does a short P-R interval cause a loud M1 ANS The P controls the timing of atrial contraction, which raises left atrial (LA) pressure. The force of the contraction opens the mitral valve further at the end of diastole. The R controls the timing of ventricular contraction. If the P-R interval is short, ventricular contraction occurs so quickly after the atrium has contracted that the LA has not had time to relax (short X descent). Therefore, atrial pressure is still at a high level when the...

Decreasing Peripheral Resistance with Nitrites

How does amyl nitrite affect blood pressure and cardiac output How do its effects differ from those of nitroglycerin ANS Amyl nitrite causes an immediate and marked drop in blood pressure. After about 20 s the cardiac output is increased. Nitroglycerin causes a mild drop in blood pressure and a fall in cardiac output. 2. Why does amyl nitrite cause an increase in cardiac output whereas nitroglycerin causes a fall in cardiac output ANS The rapid and profound drop in blood pressure produced by...

References

Die angeborenen Defect de Kammerscheidewand de Herzens. Stschr. Klin. Med. 32 1, 1897. 2. Braunwald, E., et al. Idiopathic hypertrophic subaortic stenosis Description based on analysis of 64 patients. Circulation 29 (Suppl. 14) 1, 1964. 3. Leriche, R., and Morel, A. The syndrome of thrombotic obliteration of the aortic bifurcation. Ann. Surg. 127 193, 1958. 4. Marguis, R. M., and Godman, M. J. Nomenclature of the ductus arteriosus. Br. Heart J. 49 288, 1983. 5. Dressler, W. The...

Mode Of Production

Where is the S4 best recorded by an intracardiac phonocatheter, in the atrium or in the ventricle 2. What does the apex cardiogram (apex impulse tracing) show at the time of the S4 ANS It shows a hump just before the systolic outward impulse. This presys-tolic hump or A wave is often large enough to be palpable. Note The peak of the A wave coincides with the largest vibration of the S4. 3. What causes this A wave or end-diastolic outward movement on the apex cardiogram ANS It is the effect of...

The S4 in Volume Overloads

When is ventricular enlargement usually associated with a normally compliant ventricle, and therefore with an absent S4 ANS When the volume overload is chronic due to regurgitation or shunt flows, i.e., in ventricular septal defect (VSD), persistent ductus arteriosus (PDA), chronic aortic regurgitation (AR), or chronic mitral regurgitation (MR). 2. When will there be an S4 in a subject with MR a. Secondary to papillary muscle dysfunction or LV dilatation due to fibrosis or ischemia. b. Sudden...

The Narrowly Split S2

List the usual causes of a narrowly split S2 due to a delayed A2. ANS a. Conditions that cause electrical delay of LV conduction, such as left bundle branch block (LBBB). b. Conditions that increase the volume of the LV but without an extra outlet (a VSD or mitral regurgitation MR is an extra outlet), e.g., persistent ductus arteriosus (PDA) and AR. c. Conditions that cause a significant gradient across the outflow tract of the LV (e.g., AS), so that there is a delay in LV pressure dropping...

Factors that Make the Mitral Stenosis Murmur Softer

What can make MS diastolic murmurs soft besides mild MS, obesity, or emphysema b. A large right ventricle (RV) pushing the LV posteriorly. The RV is an anterior chamber, and if it enlarges, as it often does in MS, it pushes the LV away from the anterior chest wall. 2. What besides the mitral obstruction itself can cause a low flow in MS ANS a. Severe pulmonary hypertension. This causes an additional obstruction to flow for which RV hypertrophy and a rise in RV pressure do not compensate...

Measurement Of Venous Pressure

How can you detect jugular pulsations that are difficult to perceive ANS a. Shine a light tangentially from behind or in front of the neck to throw a jugular shadow. b. The most accurate way of finding the top level of pulsations is to examine the silhouette of the neck. When you are examining the right side of the neck, you must lean over to the left side of the patient or stand on the left side of the bed temporarily to obtain a good view of the silhouette of the skin overlying the right...

Shapes and Length

ANS In the membranous septum, i.e., in a small translucent area, extending about 1 or 2 cm below the aortic valve. Note The attachment of the septal leaflet of the tricuspid valve bisects the membranous septum, so that the usual VSD is below the attachment, but if the VSD is above this attachment it may shunt blood directly into the right atrium. Defects in the membranous septum below the tricuspid valve are the most common. Membranous septum crossed by tricuspid valve Membranous VSD below...

Etiology Pathology and Physiology of the Prolapsed Valve Syndrome

What is the usual mitral valve abnormality seen at surgery or necropsy when a prolapsed mitral valve is examined ANS Myxomatous transformation with elongated chordae. (See figure on p. 226.) On the left is a cross section of the abnormal middle scallop of the posterior leaflet. On the right is the same area from a woman with left ventricular hypertrophy but no MR. (From J. K. Trent, et al. Am. Heart J. 79 539, 1970.) 2. With what conditions have prolapsed valves been most commonly associated b....

MR Due to a Ruptured Papillary Muscle

How many chordae are capable of rupture if a papillary muscle ruptures ANS Each papillary muscle has about six heads whose chordae divide about three times before they attach to their leaflets, to each of which are attached about 120 tertiary chordae. (See figures on p. 220.) 2. What is the usual cause of a papillary muscle rupture 3. How may loudness of the murmur tell you whether a systolic regurgitant apical area murmur is due to a ruptured papillary muscle rather than to a ventricular...

Abnormal Abdominal Murmurs

What is the pitch and timing of the stenosing renal vascular lesion murmur ANS It is high-pitched, sometimes to and fro with systolic accentuation, sometimes only a short systolic murmur, and sometimes continuous. Note a. The kind of renal artery lesion that is most likely to have an arterial murmur is fibromuscular dysplasia. b. A continuous murmur means either an arteriovenous fistula of the portal system or renal artery stenosis. c. If a venous hum is present over the xiphoid region or...

How to Recognize a Pericardial Friction

What adjectives and analogies have been used to describe the quality of friction rubs ANS They are usually described as crunching, scraping, creaking, grating, crackling, or scratching. They often sound like squeaky shoes or like two pieces of sandpaper rubbed against one another. Occasionally, however, they sound no different from any mixed-frequency murmur. They often sound surprisingly superficial, and increased stethoscope pressure sometimes seems to make them unexpectedly louder. They may...

Explanation Of Normal Splitting Sequence Of S2

Draw the ventricular pressure curve and an aortic pressure curve. 2. Superimpose the aortic pressure curve on the ventricular pressure curve. Note that when the LV pressure rise exceeds aortic pressure, the aortic valve will open and produce a single-chamber effect or an aortoventricle. The point at which ejection is finished and the aortic and LV pressure curves separate is called the incisura and is simultaneous with the aortic second sound, or A2. 3. At what pressure in the left ventricle...

Causes

List the four most common causes of MR murmurs in the adult. ANS Prolapse of the mitral leaflet into the left atrium, papillary muscle dysfunction, rheumatic valve damage, and ruptured chordae. Note When a loud S1 is heard in a patient with MR, mitral valve prolapse should be considered. 2. List some rare causes of MR in the adult. ANS Left atrial myxoma, an endocardial cushion defect with a cleft anterior leaflet, and a calcified mitral annulus. Note About 10 of patients with mitral annulus...

Right Ventricular Hypertrophy RVH

What are the characteristics of a normal left parasternal impulse ANS It consists of a tiny inward (posterior) movement throughout most of systole due to the emptying of the RV. In children and in some adults, there is a smaller-amplitude initial outward movement of short duration, probably due to a change in shape of the RV during isovolumic contraction. 2. How does the left parasternal impulse caused by the RVH or pulmonary stenosis (PS) or pulmonary hypertension differ from normal ANS It is...

How To Use The Internal Jugulars As A Manometer

What reference level is used as zero ANS The sternal angle (angle of Louis). 2. What are the upper limits of normal for jugular pulsation in the (a) supine and (b) 45 position with the sternal angle as zero ANS a. The supine upper limit is 2 cm. Venous pressure can be estimated by observing the upper level of internal jugular pulsations above the sternal angle. If it is over 4.5 cm at 45 , it indicates an Venous pressure can be estimated by observing the upper level of internal jugular...

The Right Versus The Left Ventricular S3

How can you tell whether an S3 is from the RV or LV ANS a. An S3 generated by the RV is louder over the RV area, i.e., near the lower sternal area or epigastrium, unless the ventricle is markedly enlarged, in which case it may be loud over any part of the chest wall that overlies the RV. This includes those parts of the precor-dium usually occupied by the LV. b. An RV S3 is usually louder on inspiration because there is more flow into the RV. The LV S3 may be louder on either inspiration or...

Summation And Augmented Gallops

Why can a first-degree AV block augment the S4 ANS A first-degree AV block, i.e., in which the P waves come relatively early in diastole, may cause the atrium to contract early enough to coincide with rapid ventricular filling. Atrial contraction occurring at this time squeezes blood into the ventricle at the same time that rapid ventricular expansion is also drawing blood into the ventricle. Thus, a soft S4 can become very loud. Unless the P-R interval is extremely prolonged, this contraction...

The Normal Impulse Gradient Murmur and the Increased Flow Murmur

How can a systolic murmur be produced across a normal semilunar valve ANS There is always a forward pressure gradient across a semilunar valve, as there must be in any pipe with a forward flow. The gradient between the upstream and downstream manometers may not be measurable by the usual cardiac catheter techniques. If, however, the gradient is increased enough by obstruction to flow, a semilunar valve, or even a local protuberance from one wall, enough turbulence may occur to produce a murmur....

Loudness and Site

Where is the aortic systolic murmur of valvular AS heard loudest ANS Anywhere in a straight line from the second right interspace to the apex. (If the patient is obese or has emphysema, the murmur may be loudest above or on the clavicle.) 2. Where is the classic aortic area What is wrong with this term ANS This area is in the second right interspace. However, aortic valvular events can be best heard anywhere in a sash or shoulder harness area from the second right interspace to the apex. Since...

Pitch and Quality

Is the MS diastolic murmur high or low in pitch Why ANS Low, because a murmur that is produced more by flow than by gradient produces mostly low frequencies. The gradient across the mitral valve in diastole is relatively low as gradients go, no matter how severe the stenosis is i.e. even in severe MS, the maximum diastolic gradient is about 30 mmHg at the beginning of diastole and about 10 mmHg at the end. In aortic or pulmonary stenosis peak systolic gradients with moderate to severe...

Leftsided Causes Of Left Parasternal Movement

When is mid- to lower-left parasternal movement due to the LV ANS a. In young subjects with long, thin chests, the LV impulse may be very medial (i.e., at the left parasternal area). b. In some subjects in whom the LV is markedly enlarged, the movements may extend medially to the left parasternal area (as well as laterally). c. The movement may occur in the presence of a ventricular aneu-rysm, in which case it will be sustained with a late peak. 2. When is the left parasternal outward movement...

Normal Jugular Pulse Contours

What is the difference between the jugular and right atrial pulse contours ANS None for all practical purposes, except when jugular pulse tracings pick up carotid artifacts. Therefore, the right atrial contours will be explained first because it is right atrial events that produce the jugular contours. 2. What is the normal right atrial contour and what are the letters given to the important crests and descents ANS The normal right atrial contours consist of A, C, V, and H waves. However, it is...

The Pacemaker S4like Click

When can an electronic pacemaker produce an extra sound When does the extra sound occur ANS When it causes intercostal skeletal muscle contraction, it can produce a high-pitched, clicking sound just preceding the M1, so that it sounds like a widely split Sl. It is accentuated by inspiration and occurs about 6 ms after the pacing stimulus. Perforation of the myocardium of the RV by a transvenous pacing electrode should be suspected when the pacemaker-induced sound occurs. This, however, is not a...

Site Loudness and Shape

Where is the murmur of TR usually heard best In what other places may it occasionally be heard ANS It is usually heard best at the left lower sternal border. It is occasionally heard best in the epigastrium, at the right sternal border or, if the RV is very large, over the mid-left thorax at the site of the usual LV apex area, which may be taken over by the RV. When there is acute, severe TR, there may be no precordial regurgitant murmur but the massive reflux into the venous system may...

The Smooth Diaphragm

What is meant by masking of sounds ANS Masking of sounds refers to the inability to hear a sound well because of interference by another loud sound occurring just before it or just after it. 2. Do low frequencies mask high ones easily ANS Yes, unless the lower frequencies are very widely separated in pitch from the higher frequencies or are relatively soft. 3. What is the purpose of the smooth, stiff diaphragm ANS To damp out low frequencies and unmask high frequencies. If the resonance...

Pulsus Paradoxus

What is meant by pulsus paradoxus ANS It is a marked fall in systolic blood pressure on inspiration. 2. Does the systolic blood pressure normally increase or decrease with inspiration Why a. Lung capacity increases with inspiration and the pulmonary vascular bed expands so that less blood moves from the lung into the left heart. b. Intrathoracic pressure decreases with inspiration. Because the aorta is an intrathoracic organ, its pressure will also drop. 3. Why did the term paradoxus come into...

Xray Evaluation Of Cardiac Size

How is determination of cardiac size by X-ray usually calculated ANS By cardiothoracic (C T) ratios. Fifty percent is considered by most radiologists to be the upper limit of normal. 2. How can we overcome the falsely normal C T ratios in subjects who are short and underweight, or the falsely high C T ratios in subjects who are overweight ANS By the use of the height and weight tables of Ungerleider and Clark 4 . 3. How can you measure cardiac volume to derive a more accurate cardiac size than...

And The Severity Of Mitral Stenosis

What are the major factors controlling the duration of isovolumic relaxation, or the 2-OS interval ANS a. The pressure at which the aortic valve closes (near systolic pressure). b. The pressure in the LA at the time the mitral valve opens. 2. What is the relationship between the degree of MS and the height of the V wave in the LA ANS The greater the stenosis, the greater the obstruction to flow and thus the slower and more incomplete is the emptying of the LA. Therefore, the greater the MS, the...

The Crescendo Murmur to the Mt in Mitral Stenosis The Presystolic Murmur

What is the appearance or shape of a murmur that is produced by atrial contraction forcing blood through a stenotic mitral valve ANS It should follow the curve of atrial pressure rise and fall, i.e., it should be crescendo-decrescendo. 2. What is the actual shape of the diastolic murmur produced by atrial contraction at the end of diastole in MS ANS It is crescendo to the first sound. This murmur is often called presystolic. 3. Does the presystolic crescendo murmur of MS extend to the M1 There...

MR Due to Ruptured Chordae

How does spontaneous rupture differ from that due to infective endocarditis ANS Spontaneous ruptures usually occur in one of the 25 major chordae closer to the papillary muscles than to the leaflets, thus involving at least four or five small terminal branches. Infective endocarditis usually involves only a few terminal branches. 2. What is the shape and frequency of the usual MR murmur of spontaneously ruptured chordae Why ANS It is a decrescendo, mixed-frequency murmur. It is decrescendo...

The A Wave X Descent C Wave and X Descent

When the P wave of the ECG occurs, what atrial event results ANS The right atrium contracts and produces a rise in right atrial pressures. Rises in atrial pressure are not named. When the right atrium relaxes, the right atrial pressure falls. The fall in pressure, when it is named, is called the X descent. (Not all cardiology texts give this descent a name 1 .) The rise and fall produces a wave universally known as the A wave. On the right atrial pressure curve, the rise in pressure resulting...

Causes of TR

Does a hypertrophied RV, due to high pressure within it (as in severe pulmonary stenosis or pulmonary hypertension) usually cause significant TR ANS No. The TR thus caused is secondary TR. It requires both a high pressure and a large volume in the RV. Note Primary TR means TR occurring without pulmonary hypertension, such as that due to trauma, to Ebstein's anomaly, or to infective endocarditis. (The latter is seen primarily in heroin addicts.) Primary TR often results in an early systolic...

Contemporary Cardiology

Aging, Heart Disease and Its Management Facts and Controversies, edited by Niloo M. Edwards, md, Mathew S. Maurer, md, and Rachel B. Wellner, md, 2003 Peripheral Arterial Disease Diagnosis and Treatment, edited by Jay D. Coffman, md, and Robert T. Eberhardt, md, 2003 Essentials of Bedside Cardiology With a Complete Course in Heart Sounds and Murmurs on CD, Second Edition, by Jules Constant, md, 2003 Primary Angioplasty in Acute Myocardial Infarction, edited by James E. Tcheng, md, 2002...

In The Left Lateral Decubitus Position

Constellation Worksheets

With the patient in the left lateral decubitus position, how can you tell that you are feeling a left or right ventricular apical impulse ANS There are two methods. Palpate the apical impulse to see if there is a sensation of a localized thrust. In the left lateral decubitus position an LV impulse feels as if a Ping-Pong ball were protruding between the ribs in systole. An RV impulse is usually more diffuse. Look for medial or lateral retraction. An LV impulse will manifest medial retraction...

Summary of How to Tell an S3 from an Opening Snap

The OS is not usually more than 100 ms (a rapid pa-pa) from the S2. The S3 is rarely less than 120 ms (0.12 s) from the A2, i.e., a relaxed two-three interval. 2. The OS is usually a short, sharp click, best heard with the diaphragm near the left sternal border. The S3 is a thud or boom, best heard by applying light or moderate pressure with the bell near the apex. 3. The OS is associated with a sharp, loud Sj. The S3 may or may not have a loud Sj. 4. An OS will separate further from the A2...

Jules Constant md facc

Clinical Associate Professor of Medicine State University of New York at Buffalo School of Medicine Humana Press Totowa, New Jersey 2003 Humana Press Inc. 999 Riverview Drive, Suite 208 Totowa, New Jersey 07512 www.humanapress.com All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher. The...

Loudness Of The S3

Which chest piece and degree of stethoscope pressure best brings out the S3 ANS The bell, applied with light to moderate pressure so that the low frequencies will not be damped out. 2. What increases the loudness of the S3, inspiration or expiration ANS Either. Expiration can make the S3 louder by squeezing blood out of the lungs into the left atrium and ventricle, and by bringing the stethoscope closer to the heart. Inspiration can make it louder by increasing sympathetic tone to the heart and...

Hypertrophic Obstructive Cardiomyopathy HOCM Murmurs or Hypertrophic Subaortic Stenosis HSS

What causes the obstruction in hypertrophic obstructive cardiomyopathy (HOCM) ANS The obstruction is usually caused by the combination of a hypertro-phied septum, which bulges into the LV outflow tract during systole, and an abnormal anterior motion of the anterior leaflet of the mitral valve. The outflow tract, which is the space between the septum and the anterior leaflet of the mitral valve, becomes narrowed when a freely mobile portion of distal mitral valve is pulled toward the septum by a...

The S4 in Myocardial Infarction

What proportion of patients with acute myocardial infarction have an S4 ANS Almost all will have a phonocardiography S4 unless they have MS or atrial infarction. It is heard by auscultation in about half of the patients during the first few days following infarction 2 . Note An infarcted area, whether dyskinetic (bulges out like an aneurysm in systole) or akinetic (no movement during systole), causes loss of compliance of the LV. Presence of excess catecholamines, which is usual in the first...

And Presence Of An S4

What does the presence of an S4 indicate about the gradient in (a) aortic stenosis (AS) and (b) pulmonary stenosis (PS) ANS a. In valvular AS it suggests a severe gradient of at least 70 mmHg across the aortic valve 5 . This is not valid either in subjects with angina, in whom ischemic heart disease may be an additional cause of an S4, or in subjects with hypertrophic obstructive cardiomyopathy (HOCM), who may have an S4 with any gradient. b. In PS it also suggests a gradient across the...

The A Wave or Palpable Atrial Hump

How does a cineangiogram show the effect of a contracting atrium on the ventricle ANS With contrast material in the LV, a cineangiogram can show that the LV suddenly expands at the end of diastole in response to atrial contraction. 2. When is this end-diastolic or presystolic expansion of the LV palpable ANS The normal A wave is not palpable. Only a very strong left atrial contraction can expand the LV with enough force to cause a palpable presystolic hump on the LV impulse. Note If the atrial...

Other Auscultatory Signs of PDA

What auscultatory signs of the increased flow through the mitral valve and large volume load on the LV may be heard in patients with a PDA ANS There may be an S3 and or a mitral diastolic flow murmur and the S2 split may be paradoxical. 2. What are the multiple clicks or crackles heard at the end of systole and the beginning of diastole called Their significance ANS Eddy sounds. They signify a large flow ductus 11 . PDA with High Pulmonary Artery Pressure 1. What causes differential cyanosis...

The Widely Split S2

What is meant by a wide split of the S2 ANS A persistent split that widens on inspiration to at least 60 ms (0.06 s). (Say pa-da as quickly as possible for 60 ms.) Note The concept of wide and narrow splitting is best understood if you practice the vocal imitation of splitting widths as follows A normal narrow split on inspiration is 30-40 ms (0.03-0.04 s). Imitate this by rolling the tongue, as in the Spanish dr or tr. For a slightly wider split of 50-60 ms (0.05-0.06 s) say pa-da quickly....

Differential Diagnosis Of The Fixed Split

What may mimic a wide fixed split of the S2 ANS a. The A2 followed by an opening snap. b. A very wide split in which normal movements of the A2-P2 are difficult to perceive by auscultation. 2. Why does the split S2 in the normal subject tend to narrow on sitting or standing ANS This happens because when both ventricles receive less blood (due to pooling in the abdomen and the legs), the RV responds by ejecting its blood relatively faster than does the LV 5 . The RV responds more to changes in...

Grading Of Heart Sounds And Murmurs

Freeman and Levine in 1933 introduced the grading of murmurs up to 6 1 . However, they did not describe either how to tell grade 3 from grade 4 or the psychological approach to grade 1 murmurs. Grading 1 to 6 is now generally accepted according to the following criteria, which serve for heart sounds as well as murmurs. Grade 1 So soft that you must tune in to hear it. Tuning in means that you must know what to expect before you can hear it. Then you can eliminate room noise psychologically and...

The S2 Split In Pulmonary Hypertension

What are the three general types of pulmonary hypertension ANS a. Hyperkinetic pulmonary hypertension, i.e., that due to excess volume flow, as in large left-to-right shunts. The pulmonary arterioles can dilate to accommodate up to three times the normal cardiac output before the pulmonary artery pressure must rise. b. Vasoactive pulmonary hypertension, i.e., that due primarily to pulmonary arteriolar constriction, as in response to either hypoxia or to a high left atrial pressure, as in...

Glossary

Aneurysm Localized dilatation of either a blood vessel or a heart chamber. The most common cause of an arterial aneurysm is atherosclerosis. Anywhere in the aorta atrophy of the media (muscular layer) deep to an atherosclerotic plaque results in either a saccular or a fusiform (spindle-shaped) dilatation. The most common site is the abdomen distal to the renal arteries. Syphilis (lues) used to be the most common cause of thoracic aortic aneurysm, usually in the ascending aorta. When infection...

The Physiological Versus The Pathological S3

What is the difference in timing and quality between the physiological and the pathological S3 ANS None, except that the S3 found in constrictive pericarditis may occur earlier than usual. 2. How can you usually tell a physiological from a pathological S3 ANS Only by knowing the circumstances under which it occurs, i.e., by finding the reason for the pathological S3, such as symptoms and signs of heart failure or myocardial abnormalities. Note Some patients with a pathological S3 secondary to a...

Relative Loudness Pitch and Duration of the S1 and S2

When is it difficult to distinguish an S1 from S2 by stethoscope alone ANS When systole almost equals diastole in duration. This is called a ticktack rhythm (like the ticking of a clock) or embryocardia (like the fetal heart sounds). 2. What causes ticktack rhythm ANS Anything that shortens diastole more than it does systole, as in tachycardia. As the heart rate increases, both systole and diastole are shortened, but diastole is shortened relatively more than systole. Note a. The heart rate in...

Right Ventricular Enlargement

How can you best palpate for movement caused by a large RV ANS a. Since the RV is an anterior structure, its enlargement may produce an increased left parasternal movement. Diffuse left parasternal movements are often best palpated with the proximal part of the palm (thenar and hypothenar areas). The movement is then transmitted to the entire arm. The shoulder becomes the fulcrum and this amplifies the hand movements that are at the end of the arm lever. b. Look for systolic downward movement...

Capillary Pulsation

How do you elicit capillary pulsation (Quincke's sign) ANS Compress the skin of the face or hands with a glass slide, or exert slight pressure on the nail beds and watch for intermittent flushing. You can also transilluminate the nail bed with a flashlight against the pad of the patient's finger while shading the finger with the other hand. 2. What is the mechanism of capillary pulsations and what noncardiac conditions can cause it ANS The mechanism is the transmission of the arterial pulse...

The S3 Versus The Opening Snap

What is the difference between the A2-OS interval and the S2-S3 interval ANS The A2-OS interval is rarely more than 100 ms (0.10 s), whereas the shortest A2-S3 interval is usually 120 ms (0.12 s). The difference between 100 and 120 ms is merely the difference between saying pa-pa as quickly as possible and saying it at a normal speaking rate. 2. How does the S3 of a tumor plop differ from the usual S3 ANS A tumor plop is the early diastolic sound produced when a left (or right) atrial myxoma...

The Valsalva Effect in Patients with Decreased Function

Boss Dimension For 3mm Screw

What is a normal ejection fraction ANS About 70 10 of the end-diastolic volume that is ejected during systole by angiography. 2. What is the blood pressure response to a Valsalva strain if the ejection fraction is normal, i.e., 70 10 by angiography, or 60 10 by radionuclide methods ANS If the cuff pressure is held at 25 mmHg above systolic pressure during the strain, a few Korotkoff sounds heard at the beginning of the strain reflect the increased intrathoracic pressure. Then the Korotkoff...

The Aortic Sclerosis Murmur

What percentage of patients over age 50 have an easily audible aortic ejection murmur without valvular stenosis ANS About 50 . Echoardioqrams have shown that many elderly patients have a septum that bends into the outflow tract, the so-called sigmoid septum sigma Greek S . This could create enough turbulence to mimic the murmur of aortic valve sclerosis sclerosis Greek hard . Therefore a more nonspecific terminology should be used. Since about 50 of patients over age 50 have the murmur...

The V Wave and Y Descent

Pressure Tracing

When does RV contraction become too weak to continue pulling down the base How does this affect right atrial pressure ANS The phase of reduced ejection occurs in mid-systole. This attenuates the descent of the base and allows the filling of the right atrium from the venae cavae to raise right atrial pressure. This rise in pressure during systole is not named. The C wave and X' descent. Most authors use the letter X to name both atrial relaxation and the fall in pressure due to the descent of...

Physiology and Etiologies

Qrs Arterial Pressure

What is meant by a reversed or paradoxical split of the S2 ANS This is a split in which the order of components is P2A2 instead of the normal A2P2. 2. Can too early a P2 cause a reversed split ANS A reversed split is nearly always caused by a delayed A2. 3. What can delay the A2 enough to cause a paradoxical splitting ANS a. Conduction defects that delay depolarization of the LV, such as complete LBBB and some types of Wolff-Parkinson-White W-P-W preexcitation that imitate LBBB. Note The...

The Humming Systolic Ejection Murmur

What adjectives have been used to describe the quality, or timber, of the humming innocent ejection murmur that is found in children What eponym has been used for it ANS It has been described as a buzzing, vibratory, twanging, moaning, or groaning murmur. It has also been called Still's murmur, after the British author of a pediatric textbook published in 1918, who described it as a twanging string murmur. 2. Why was it thought by some to be an aortic murmur ANS A fine vibration can...

The LV Impulse in Left Ventricular Hypertrophy LVH

How can you establish by palpation that an LV apex beat is normal, i.e., that there is no hypertrophy, dilatation, or loss of compliance ANS In the supine and left lateral decubitus positions the normal apex beat rises in systole and falls away rapidly to reach the S2 at the bottom of the fall or even before the last one-third of systole. This is not a visual phenomenon, so only compare what you hear with what you feel. This depicts a normal apex impulse apex cardiogram, or ACG recorded over...

Ejection Sound in Pulmonary Hypertension

Phonocardiogram Trace

Why is an ejection sound heard in pulmonary hypertension ANS The high pressure in the pulmonary artery may dilate the pulmonary artery root, and the valve ring will be stretched. The tautened cusps, opening at a very rapid rate, probably produce the sound or click. This high-frequency phonocardiogram and simultaneous carotid tracing is from a patient with severe pulmonary hypertension secondary to a VSD Eisenmenger syndrome . Note that the pulmonary ejection E J sound does not diminish with...

Sites of A2 and P2 Loudness

What is wrong with using the expression A2 is louder than P2, or vice versa ANS If by A2 is meant the entire second sound in the second right interspace and by P2 is meant the entire second sound in the second left interspace as was true before 1960 , then it has no meaning. If it refers to individual components of a split second sound, then A2 is louder than P2, or vice versa may have meaning. 2. Which component of the S2 is best heard in normal subjects at the second left interspace...

The Cannon Wave

ANS It is the high A wave caused by atrial contraction against a closed tri-cuspid valve. 2. When will the atrium contract against a closed tricuspid valve ANS When there is atrioventricular dissociation or when a very early P wave occurs on a T wave, as with a premature atrial contraction or a junctional pacemaker. Note that in this patient with complete atrioventricular block, every other P wave happens to fall on a T wave, i.e., it occurs during ventricular systole when the tricuspid valve...

Other Causes of Continuous Murmurs

What is meant by a pulmonary arteriovenous fistula ANS This is a right-to-left shunt from pulmonary artery to pulmonary vein. It is usually congenital. 2. By inspection alone, what clues indicate that the continuous murmur is due to a pulmonary arteriovenous fistula. ANS Cyanosis, clubbing, and telangiectasia on the skin or mucous membranes. 3. What should you suspect as a cause of a continuous murmur that is heard bilaterally in a patient with cyanosis and a roentgenogram that suggests no...

Characteristics Of The Ejection Murmur

What valvular flow event is implied by the term ejection murmur ANS The term implies a murmur that is produced by blood flowing forward through a semilunar valve aortic or pulmonary valve during systole. 2. What is characteristic of ejection murmurs on a phonocardiogram ANS They start with the final component of the first heart sound S1 are diamond, rhomboid, or kite-shaped and finish before the second sound of the side of the heart from which the murmur originates. This means that a...

Leg Blood Pressure in Aortic Regurgitation

How does AR affect the blood pressure in the legs in comparison with that in the arms What is this sign of AR called ANS AR exaggerates the tendency for the leg systolic pressure to be higher than that in the arms. If the difference is greater than normal, i.e., more than 20 mmHg, it is known as a positive Hill's sign 7 . Note It is easy to remember because blood pressure increases, i.e., goes uphill in AR as the examiner goes down the body. 2. Why is the cuff systolic pressure in AR higher...

The Auscultogram

Cardiology Auscultation

A graphic method for illustrating auscultatory findings is offered here, not only as a means of keeping records as conveniently and efficiently as possible, but also as an aid in learning auscultation. One such auscultogram see figures can equal a 629-word description of the auscultatory findings. The graph can tell the story at a glance once the symbols are understood. Filling in such auscultograms serves a self-teaching function in training a person in auscultation, because one is forced to...

Hepatojugular Reflux

What is the cause of a high venous pressure in a person with low cardiac output ANS a. Increase of venous tone due to sympathetic outflow and catecholamines. b. Increased blood volume due to salt and water retention, probably at least partly due to the increased sympathetic outflow effect on the kidneys. One may therefore characterize a high venous pressure in heart failure as due to an increase in tone volume. 2. What can cause a patient with heart failure to have an apparently normal...

Causes of a Loud A2 or P2

What conditions tend to make the aortic component of the second sound louder than normal ANS a. Conditions that raise aortic systolic pressure, e.g., systemic hyper tension, which occasionally produces a drumlike sound or tambour S2. A tambour is a small drum that is covered only on one side. The tambour effect may persist even after the blood pressure has been lowered to normal by medication. b. Conditions that produce a hyperkinetic systemic circulation, e.g., youth, or thyrotoxicosis. The...

Physiology Of The Normally Moving Split

Does the normal split of the S2 widen on inspiration or expiration ANS It widens on inspiration, so that the A2P2 becomes an A2-P2. 2. Does the split movement of the S2 occur because of the movement of the A2 or the movement of the P2 ANS Both. The P2 moves out, away from the A2, and the A2 moves inward, away from the P2. 3. Which component moves more, the A2 or the P2 The P2 outward movement contributes more to the inspiratory widening of the S2 than does the inward movement of the A2. The...

The Austin Flint Murmur Versus the Mitral Stenosis Murmur

Diastolic Rumble Apex

What is the Austin Flint murmur 4 ANS It is an apical diastolic rumble imitating the murmur of organic MS but is due to an aortic regurgitation AR stream that prevents the mitral valve from opening fully. 2. What is the most plausible theory explaining the mechanical cause of the Austin Flint murmur ANS The AR stream may impinge on the undersurface of the anterior leaflet of the mitral valve and push it up, creating a relative MS. Support for this theory is found in the following a. A yellow...

The Exaggerated Physiological S3

List the common shunts and the valvular lesion that may cause excessive flow through the mitral valve, therefore exaggerating or bringing back the physiological S3. ANS a. The two left-to-right shunts, ventricular septal defect VSD and persistent ductus arteriosus PDA . Atrial septal defects ASDs do not increase flow through the mitral valve. b. An incompetent mitral valve, i.e., mitral regurgitation MR . Low-frequency phonocardiogram from a 15-year-old girl with severe rheumatic MR. Besides...

Palpability of the Apex Beat

About how often can you expect to feel an apex beat in normal subjects over age 40 ANS Only in about one out of five 1 . However, in about 90 of children and teenagers, an apex beat is palpable in the sitting position. An apex beat is much more likely to be palpable in the sitting than in the supine position because in the latter, the heart falls away from the anterior chest wall. In the left lateral decubitus position, however, the apex beat may be palpable in about four out of five older...

The Straight Back Syndrome Ejection Murmur

What is meant by the straight back syndrome ANS Compression of the heart due to loss of the normal dorsal curvature of the spine, resulting in a pulmonary ejection murmur that is usually mistaken for that of either PS or ASD. 2. Why will loss of the normally gentle dorsal kyphosis cause a pulmonary ejection murmur ANS The upper mediastinal structures, including the pulmonary artery, may be compressed against the sternum, and can actually produce a gradient of 5-15 mmHg across the pulmonary...

What Does A Venous Hum Sound Like

Where is the venous hum best heard ANS Just above the clavicle, either medial to the sternocleidomastoid muscle or between its insertions. A venous hum is more likely to be heard on the right side because the right jugular is larger than the left, since it must carry about two-thirds of the intracranial venous drainage. 2. What does a venous hum sound like ANS Sometimes like a continuous roar at other times like the sound of the sea heard by putting a seashell to the ear and sometimes as a...

Leg Pulses and Blood Pressure in Coarctation of the Aorta

When should you suspect coarctation of the aorta ANS In any patient with hypertension. 2. What are the characteristics of the pulses proximal to and beyond an aortic coarctation ANS The proximal pulses, i.e., the carotid and brachial pulses, are large, bounding pulses. The parts of the body beyond the coarctation i.e., usually beyond the left subclavian artery receive blood through enlarged collaterals that do not transmit the percussion wave well. Therefore, not only do the lower extremity...

Contents

A Complete Course in Heart Sounds and Murmurs on CD Advantages of a Checklist 1 Reminder List History 2 Etiologies 3 Follow-Up Questions 7 New York Heart Association Functional and Therapeutic Classification 14 3 Arterial Pulses and Method of Arm Palpation 29 Rates of Rise and Pulse Volume 30 Pulsus Bisferiens 37 Palpation of the Leg Pulses 38 Estimating Systolic Blood Pressure by Palpation Alone 39 Accurate Blood Pressure Measurement 40 Diastolic Blood Pressure Recording 45 Accuracy of Blood...