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Cardiac semeiotics: cardiovascular examination

  1. Gastroepato
  2. Cardiology
  3. Cardiac semeiotics
  4. Auscultation of heart
  5. Practical anatomy of
    the heart and large vessels
  6. The circulatory system
  7. Chest pain

notes by dr Claudio Italiano

The objective examination of a cardiopathic patient requires the systematic investigation of the jugular pulse of the carotid and of the body, as well as a careful listening. The evaluation of the patient with a suspected cardiovascular disease requires a precise history and an accurate objective examination. In the cardiopathic patient approach, the "five fingers" rule, by dr. W. Proctor Harvey, only that today we have to replace the old x-ray of the heart from afar, that is the radiological investigation with which we obtained the cardiac silhouette, with the most recent echocardiography of the heart.
Therefore the steps of the approach are:

1) anamnesis of the patient
2) objective examination
3) electrocardiography
4) echocardiography
5) second level exams

A patient's cardiovascular evaluation is well performed if the findings of the jugular venous pulse, carotid pulse, pulp-type and listener are systematically considered.

Diagnosis of heart disease are usually obvious?

No, just the opposite. For example, in the case of a patient with angina pectoris, what do we appreciate? At the listener a fourth pronounced heart tone is highlighted. At the apex a prolonged systolic murmur is heard, which radiates to the left marginaltern. It could be a murmur of mitral insufficiency due to dysfunction of the papillary muscles, not uncommon in ischemic heart disease. The differential diagnosis should be extended to include other causes of angina, such as subaortic stenosis, idiopathic hypertrophy of the myocardium. Proper maneuvers are carried out on the bedside of the patient and it is found that the murmur is reduced considerably as soon as the patient assumes the crouched position, while it is accentuated in orthostatism and after the patient is made to inhale amyl nitrite.

The correct diagnosis is subaortic stenosis. Rarely a single finding (as the presence of a mesosisteric click and a telesystolic murmur) has diagnostic value. More often than not, as in the example just given, a constellation of signs is necessary to make a diagnosis.

How to inspect and palpate precordial impulses?

Carry out a careful examination of the precordium in each of the areas indicated in the so-called "mucus-aortic walk". Recommend the patient to empty the lungs from the air so that the chest wall is as close as possible to the cardiac structures. Among the main anomalies present in the left parasternal area are: hypercinetic pulse - characteristic of interatrial septal defects -, prolonged systolic pulse - characteristic of right ventricular hypertrophy - and telesystolic impulse - characteristic of hemodynamically significant mitral insufficiency. Areas of left ventricular dyskinesia can be seen as systolic impulses in an ectopic zone or as a diffuse apical fish. The fish should be evaluated both in the supine position and in the left lateral decubitus. With the patient supine, focus on the duration of the impulse. If the duration is prolonged, an increase in left ventricular mass is almost always present. The left lateral decubitus is the best position for palpating diastolic events, such as a presystolic distension due to vigorous atrial contraction, or a rapid ventricular diastolic movement. Often, in patients with advanced cardiovascular disease, there is a rebound movement of the entire precordium. This movement is due to the presence of a short systolic pulse and a prevailing diastolic pulse and represents the sum of the atrial contraction and the rapid filling wave.

How to focus on some particular signs of listening?

Cardiac listening is conducted in the classical areas paying attention to a cardiac event at a time. It is what is called the "selective listening" technique. You can selectively hear each tone or heart murmur or you can "exclude" them. The doctor assesses whether the first cardiac tone has weak, strong or normal intensity, if it is a single or double tone. The first cardiac tone is weak in cases of weak ventricular contraction or prolongation of the P-R interval and reinforced in the case of a short P-R interval or a vigorous ventricular contraction (as occurs in hyperkinetic conditions, anemia or thyrotoxicosis).

Is the second heart tone unique or split? Is it strong or weak? The intensity of the second tone can be increased by an increase in the aortic or pulmonary component. In closed aortic stenosis, because the valve closes late, in the insufficiency of the aortic valve or in the left bundle branch block there will be a paradoxical doubling of the second tonocardia. A pulmonary closure delay as occurs in the right bundle branch block or in pulmonary stenosis, causes a split of the second cardiac tone. A doubling of the second cardiac tone may also be due to an advance of the aortic component, caused by an early closure of this valve as occurs in interventricular septal defects. A fixed and broad doubling of the second cardiac tone implies the presence of a defect of the interatrial septum.

What are the gallop tones and what is the best way to evaluate them?

Galloping tones (third or fourth heart tones) are low-frequency diastolic events that are best heard by lightly resting the bell of the stethoscope in the chest. The third and fourth left ventricular heart tones are better heard at the left ventricular apex. The left ventricular apex is localized with the finger; the bell of the stethoscope is placed slightly at the apex causing a small gap in air. Often there is no anomaly except by placing the patient in a left lateral recumbency. In this position, pronounced fourth or third cardiac tone are commonly detected, not audible with the patient in a supine position. The right ventricular gallop tones are heard better along the lower portion of the left marginosternal and the right ventricular origin of these tones is reported by the characteristic increase in intensity at the inhalation. These rhythms of dilated cardiopathy with severe pump failure are an expression.

How to recognize the murmurs and how to define their character?

The identification of the murmurs is based on factors such as localization, quality, temporal correlations and the murmur from aortic stenosis is better heard at the second right intercostal space and is transmitted to the carotid. It can be heard well at the apex. It is easy to identify the murmur from a mitral insufficenza, a high-frequency pansystolic murmur, heard at the apex radiating to the axilla. The mitral stenosis murmur is a low-frequency diastolicxxo event limited to the left ventricular apex. The murmur from aortic insufficiency is a high frequency diastolic murmur heard on the marginosternal. Ejection blows through the pulmonary valve, present in interatrial septal defects, are also easy to identify. A delayed closure of the aortic valve, as in severe aortic stenosis, in severe aortic insufficiency or in the left bundle branch block, causes paradoxical doubling of the second cardiac tone. However, many heart murmurs do not correspond to these classic descriptions and in this case special maneuvers must be carried out.


What particular maneuvers are useful in this regard?

 It is often possible to identify atypical puffs by observing alterations in intensity and / or duration following changes in patient's position, inhalation of amyl nitrite, Valsalva maneuver or prolonged isometric narrowing of the hand, or observing possible variations of the murmur during murmuring or after extrasystole. The stenosis and insufficiency of the tricuspid puffs increase in intensity at the inhalation. 1 puffs from left ventricular outflow obstruction increase after extra-systolic, while insufficiency puffs are little affected by extrasystoles. The idiopathic hypertrophic subaortic stenosis murmur may disorient. It is of the systolic type and is heard better along the left marginal and at the apex. It does not radiate to the carotid or axilla. It can be gentle, simulating an innocent murmur or an ejection blow through a sclerotic aortic valve. If it is of high intensity and prolonged it is very often mistaken for the murmur by insufficiency of the mitral or interventricular septal defect. The idiopathic hypertrophic subaortic stenosis murmur is generated via the left veritricular outflow canal between the upper portion of the interventricular septum and the anterior mitral limb. Maneuvers that reduce left ventricular volume decrease peripheral vascular resistance or increase contractility, accentuate the obstruction and then the murmur. Maneuvers that increase ventricular volume, increase vascular resistance or depress contractility, reduce murmur. In all patients presenting an unspecific precordive murmur, one should proceed to a supine, orthostatic and crouched position.

The squatting position increases venous return and peripheral vascular resistance and therefore causes a reduction in idiopathic hypertrophic subaortic stenosis. Often this happens in a striking way. As a result of the patient's rapid squatting, the murmur may disappear to re-show some beats with greater intensity after the patient has risen. Proceeding to listen to the patient in a supine, sitting, orthostatic and squatting position is also useful in case of suspected mitral valve prolapse syndrome.

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The patients with this syndrome have various signs, from the isolated mesosisteric click and the telesistatic murmur to several clicks or a pansystic murmur (with or without clicks). The maneuvers that reduce the left ventricular volume cause an accentuation of the prolapse, anticipating the appearance of the click during the systole and prolonging the duration of the murmur. The murmur from aortic insufficiency is better heard with the patient bent forward after forced expiration. Another maneuver that accentuates the murmur from aortic insufficiency is the squatting position. A very useful maneuver is to put the patient in a supine position and let him inhale amyl nitrite. The maximum dilatation effect of the anyl nitrite occurs 15-30 seconds after inhalation and disappears in about three minutes. Amyl nitrite reduces peripheral resistance, resulting in increased thrown and heart rate. After inhalation of amyl nitrite all left ventricular ejection blows increase, including those with fixed valvular stenosis, as well as those with hypertrophic subaortic stenosis. Amyl nitrite reduces peripheral vascular resistance and therefore the intensity of the aortic insufficiency murmur and the Austin Flint murmur associated with it; It is therefore useful to distinguish the murmur from mitral stenosis - which increases after inhalation of this substance - from the murmur of Austin Flint, which instead decreases. Prolonged isometric narrowness of the hand increases cardiac output, heart rate and blood pressure, and therefore accentuates the suffuses from insufficiency, from mitral stenosis and from aortic insufficiency.

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