Cardiac Ausculation in the Elderly

Transcription

1 Cardiac Ausculation in the Elderly 박성하 신촌세브란스병원심장혈관병원심장내과 Anatomy Surface projection of the Heart and Great Vessels Evaluating pulsation Superior vena cava Rt. pulmonary artery Right atrium Right ventricle Aorta Lt. pulmonary artery Pulmonary artery Left ventricle Apical impulse carotid Dorsalis pedis femoral Post. tibial Arterial Pulse Arterial Pulse

2 Palpation Thrill Systolic thrill -AS: Rt2nd, 3RD ICS, suprasternal notch, jugular - VSD: Lt 4th, 5th ICS - PS, ASD: Lt 2nd ICS - MR: apex to left axilla Diastolic thrill -MS: apex - AR, Ascending aorta dissection: Rt parasternal border Continuous thrill -PDA -AV fistula Maximal intensity and radiation of six isolated sys. murmurs Auscultation Auscultation High- and Low-frequency Sounds Explained Cardiac apex Left lateral decubitus position Mid-sternal edge Leans forward with breath held in full respiration Timing of Cardiac Sounds S1(first heart sound) : MV closure

3 박성하 : Cardiac Ausculation in the Elderly Ej (ejection sound) : AV opening S2 (second heart sound) : AV closure OS (Opening snap) : MV opening S3 (third heart sound) : LA LV diastolic filling S4 (fourth heart sound) : Atrial contraction Auscultation Rate & regularity Heart sounds especially intensity and quality of S2, as well as extra sounds (S3, S4) Murmurs Clicks Rubs

4 I II III IV V Intensity of murmurs barely audible Soft, but easily audible Moderately loud Louder, with a thrill Audible with stethoscope barely on chest VI Audible with stethoscope off chest Systolic Murmur - ejection vs regurgitant Regurgitant: Pansystolic murmur occurs with S1 MR Ejection: Mid-systolic murmur occurs after S1 AS Systolic Murmurs Selected causes of systolic murmur Abnormal cardiac structure 1. Aortic stenosis 2. Hypertrophic cardiomyopathy 3. Mitral regurgitation 4. Mitral valve prolapse 5. Ventricular septal defect 6. Pulmonic stenosis 7. Tricuspid regurgitation 8. Atrial septal defect Normal cardiac structure, increased flow 1. Anemia 2. Thyrotoxicosis 3. Sepsis 4. Renal failure with volume overload 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% How to rule out pathologic systolic murmur 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: Etchells E et al. JAMA 1997;277: Reichlin S et al. Am J Emerg Med 2004;22:

5 박성하 : Cardiac Ausculation in the Elderly Criteria of pathologic murmur > 2/6 grade systolic murmur with maximal intensity at RUSB 2 nd ICS Abnormal EKG Murmur or thrill over right carotid, clavicular area Prolonged, blunted cardiac upstroke Soft or absent S2 Das P et al. Q J Med 2000;93: AS Aortic stenosis Ejection: Mid-systolic murmur occurs after S1 Integrating pulse with sounds and murmur Carotid pulse for timing murmur occurs w/ upstroke sound occurs near peak murmur is systolic sound is S2 Compare with normal carotid normal peaks well before S2 carotid peak is delayed carotid peak is weak murmur is midsystolic murmur ends before S2 Ejection sound at 3RICS Hemodynamics and flow Pressures: LV-Ao pressure gradient throughout systole murmur occurs w/ upstroke CW Doppler: high velocity outflow reaches peak of 5 m/sec est. 100 mmhg gradient Severe AS: LV pressure rises increases LV-Ao gradient murmur peaks later Mitral regurgitation Chronic MR apex beat displaced to 7LICS outward excursion of stethoscope head during systole MR Regurgitant: Pansystolic murmur occurs with S1 blowing murmur with outward excursion of stethoscope a thudding sound with inward return of stethoscope murmur is holosystolic heard best over LV sound is S

6 Patient 07 Acute MR rocking stethoscope by LV left subcostal heave (RV) Early systolic murmur begins with sharp S1 Isolated, clear S2 S3 rumble Mitral valve prolapse Hemodynamics of Acute and Chronic MVP S1 click S2 S1 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 Compensation: 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)

7 박성하 : Cardiac Ausculation in the Elderly Diastolic Murmur Rumbling murmur : Early and mid. Diastolic Murmurs MS Early-diastolic murmur : AR Mitral stenosis Mitral Stenosis subtle monophasic pulses in suprasternal notch (carotid) conspicuous biphasic pulses (JVP), are a-wave dominant stethoscope displays RV lift during systole MS S1 S2 OS S1 loud S1 (coincides w/ a-wave) split S2 is fixed S2 opening snap (OS) Patient 05 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 JVP is a-wave dominant a-wave occurs with loud S

8 Add / Remove sounds Loud S1: elevated LA pressure mitral valve closes later, and more loudly than normal Opening Snap: mitral valve opens earlier than normal ( LA pressure) fused leaflets abruptly halt mitral valve opening, causing OS Mid-diastolic murmur: corresponds w/ LA-LV gradient Hemodynamic effects of heart rate 80 bpm: tachycardia exacerbates LA emptying dysfunction loud S1 loud MDM, PSM 110 bpm: 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 Aortic Regurgitation Acute severe, rapid heart rate Examination at 3LICS bounding (Corrigan's) pulse to-fro systolic & diastolic murmur harsh midsystolic murmur abbreviated early diastolic murmur initiated by a loud S2 AR Inspection of nailbed light compression of fingernail blanching & blushing of nailbed Patient 02 Well-tolerated aortic regurgitation Carotid pulse visible at suprasternal notch normal upstroke upstroke occurs near S1 Jugular venous pulse visible at right supraclavicular fossa biphasic displaces neck chain EDM is long (holodiastolic) sounds like whispered R longer murmur = better tolerated

9 박성하 : Cardiac Ausculation in the Elderly Aortic Regurgitation bounding (Corrigan s) pulse head bobbing (Musset s sign) compare with normal carotid To-fro murmur Midsystolic murmur Early diastolic murmur 3RICS To-FRO 2RICS TO-fro Chronic vs. Acute Aortic Regurgitation Chronic: at Base: MSM (Ao outflow) EDM (Ao regurgitation) at Apex: Austin Flint (mitral inflow) split S1 (S1 + ejection sound) Acute: at Base: MSM (Ao outflow) EDM is abbreviated at Apex: Austin Flint (mitral inflow) absent S1 (ejection sound only) Third Heart Sound S3 S3 (third heart sound) : LA LV diastolic filling Fourth Heart Sound S4 Gallop S4 (fourth heart sound) : Atrial contraction

10 S3 and S4 Splitting of the Second Sound Associated with abnormal S3,S4: Summation gallop Fixed S2 splitting with respiration Inspiration Expiration Atrial septal defect Venous return Venous return S1 A2 P2 S1 A2 P2 Inspiration In ASD Venous return Expiration L R shunt Fixed S2 split!! L R shunt Venous return Mid systolic murmur and S2 split at 2 nd 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-fro- FRO)

11 박성하 : Cardiac Ausculation in the Elderly Summary of Heart Sounds & Murmurs