Dynamic auscultation


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Dynamic auscultation

  2. 2. • This is a technique of altering circulatory dynamics by means of a variety of physiological and pharmacological maneuvers and determining their effects on heart sounds and murmurs
  3. 3. Interventions most commonly employed are • Respiration • Postural changes • Valsalva maneuver • Isometric exercise • Premature ventricular contractions • Vasoactive agents- amyl nitrite ,methoxamine ,phenylephrine
  4. 4. RESPIRATION • History • Pontain in1866 was the first to note the normal respiratory variation in splitting of the second heart sound . • In 1954 leatham brought pontain’s observations to clinical attention through emphasis on their significance
  5. 5. • Hemodynamics • On inspiration the intra thoracic pressure decreases and results in augmentation of right heart blood flow and decrease in left heart flow • Murmurs generated in the right heart there fore generally become louder on inspiration and those in left heart chambers decrease as a result of reduced left heart flow as well as increased insulation by the air filled lungs
  6. 6. • Second heart sound • Respiration alters the splitting and loudness of second heart sound • In normal young adults in supine position inspiration S2 split increase expiration split narrows and s2 becomes single • Failure of S2 to fuse in EXP may occur in normal children and 15 to 20 % of young adults • In up to 50% of normal adults > 50 yr single audible S2 is seen in supine position both in INSP and EXP
  7. 7. • During inspiration A2 becomes softer because 1. aortic pressure decreases 2. increased lung space between heart and chest wall • During ispiration P2 becomes soft in 2nd LICS and • Louder in lower LSB ( increased flow in the pulmonary artery has greater effect lesser deree of lung space interposed in this area )
  8. 8. Heart sounds Accentuated during Inspiration • RVS3 and RVS4 • Tricuspid OS Expiration • LVS3 and LVS4 • mitral OS
  9. 9. Pulmonary ejection click • Inspiration diminish intensity of valvular PEC • PA diastolic pressure is very low • Inspiration causes elevation of RV DP • RV late diastolic Pr almost equlises PA diastolic Pressure • Causes partial presystolic opening of PV • Less upward motion of valve during systole
  10. 10. MURMURS • Respiration exerts more pronounced and consistent alterations on murmurs of right side than left side • Especially tricuspid murmurs 100% sensitivity, 88% specificity • Inspiration increases venous return to right side of heart • Expiration increases venous return to left side of heart
  11. 11. Murmurs accentuated during Inspiration • TS • TR (Carvallo’s sign) • PR • Mild or moderate PS • Severe PS no further increase in gradient Expiration • MS • MR • AS • AR • VSD • Pericardial rub (AP diameter)
  12. 12. MVP • MSC and systolic murmur occur earlier during systole in inspiration • Inspiratory reduction in LV size • Increased redundancy of MV • Increase valvular prolapse
  13. 13. • IHSS murmur may decrease in loudness and intensity with inspiration • This is because of inspiratory increase in Lv transmural pressure, with resultant decrease in LVOT obstruction
  14. 14. • In general it is best to assess respiratory variation during normal respiration. • Effects of inspiration on auscultatory findings may be accentuated by Muller maneuver • Converse of Valsalva Maneuver • Forced inspiration against closed glottis • Forcibly inspires while the nose is held closed and mouth is firmly sealed for about 10 sec.
  15. 15. • Patients who have pulmonary hypertension and severe RVF may not demonstrate inspiratory augmentation of Rt heart murmurs and gallops • This is due to high Rt heart filling pressures that does not allow venous return to increase in inspiration • By requesting these patients to stand and by repeating cardiac ausculation we can appreciate the expected respiratory changes
  16. 16. • Widens split S2 and augments murmur and filling sound originating in right side of the heart.
  17. 17. POSTURAL CHANGE RAPID STANDING • Decrease in venous return, thus stroke volume and the ensuing reflex increses the cardiac rate and systemic vascular resistance immediately
  18. 18. • Width of the splitting become reduced • No change in patients with true fixed split Decrease in intensity • RVS3 and RVS4 • LVS3 and LVS4
  19. 19. Decrease in intensity • Semilunar valve stenosis • AV valve regurgitation murmurs • VSD • Most functional systolic murmurs
  20. 20. • Since LV EDV is decreased Increase in murmurs • HOCM(95% sensitivity, 84% specificity) • Early MSC and murmur of MVP
  21. 21. • Physiological changes that cause increase in obstruction in LVOT include a smaller ventricular size and reflex inotropic stimulus from increased catecholamines
  22. 22. SQUATTING • Sudden change from standing to squatting position • Increase venous return and augmentation of peripheral resistance due to kinking of femoral arteries simultaneously • Squatting abruptly increases ventricular preload and afterload • Arterial pressure rise may cause transient reflex bradycardia
  23. 23. Increase in stroke volume causes augmentation of • S3 and S4(of both ventricles) • Right sided systolic murmurs • AS • Diastolic murmur of MS augmented due to increase in CO with increased flow across mitral valve
  24. 24. Elevation of arterial pressure • Increase in aortic reflux AR • Increase in MR volume • Increase in LT to RT shunt in VSD • Increase in blood flow through RVOT in TOF
  25. 25. Combination of elevated arterial pressure and venous return • Increase LV size and reduce LVOT obstruction • Decrease murmur in HOCM(95% sensitivity, 85% specificity) • Click and murmur of MVP delayed
  26. 26. LEFT LATERAL RECUMBENT POSITION Accentuate intensity of • S1 • LVS3 and LVS4 • OS of MS • Murmurs of MS and MR • Click and murmur of MVP • Austin Flint murmur
  27. 27. SITTING AND LEANING FORWARD • Accentuate AR and PR murmur (mechanical)
  28. 28. Lying flat or passive leg raising in supine position • Results in increase in venous return with sequential increase in right and then left ventricular end diastolic volumes, stroke volume, and ejection velocities
  29. 29. • Augmented • Valvular AS/PS murmurs • TR murmur • S3 and S4 • Diminished • EDM of AR • Murmur of HOCM • MVP murmur and click are delayed
  30. 30. ISOMETRIC EXERCISE • This can be carried out by using a calibrated handgrip device or a handball • Better to carryout bilaterally • Performed in supine posture • Should be sustained for 30 to 40 secs • Valsalva maneuver during the handgrip must be avoided • Contraindicated in patients with myocardial ischemia and ventricular arrhythmias, severe HTN, cerebral ischemia
  31. 31. • Hemodynamic effects • Increases cardiac contractility cardiac output arterial pressure without significant change in ventricular chamber size
  32. 32. Isometric exercise results in significant increase in • Systemic vascular resistance • Arterial pressure • Heart rate • COP • LV filling pressure • Heart size
  33. 33. • Systolic murmur of AS diminished –reduction of pressure gradient across AV • Diastolic murmur of AR and systolic murmurs of rheumatic MR and VSD increases • LVS3 and LVS4 accentuated • Diastolic murmur MS becomes louder – increase in flow across valve
  34. 34. Increase LV volume • Systolic murmur of HOCM decreased • Click and murmur of MVP delayed
  35. 35. VALSALVA MANEUVER • Forced expiration against a closed glottis Standard test consists of asking the patient to blow against an aneroid manometer and maintain a pressure of 40mmhg for 30seconds
  36. 36. • Relatively deep inspiration followed by forced exhalation against a closed glottis for 10 to 20 seconds • Physician has to keep flat of the hand on the abdomen to provide the patient a force to breathe against • Normal response has four phases
  37. 37. PHASE I • Intrathoracic pressure rises • Transient increase in LV output and SBP
  38. 38. PHASE II STRAINING PHASE • Systemic venous return decrease • Filling of right and then left side reduced • Stroke volume reduced • Mean arterial and pulse pressures falls • Reflex tachycardia
  39. 39. Since LV volume is reduced • Murmur of HOCM increased(65% sensitivity, 95% specificity) • Systolic click and murmur of MVP commence earlier
  40. 40. PHASEIII VALSALVA RELEASE • Brief sudden Decrease SBP • Due to sudden decrease in intra thoracic pressure
  41. 41. • Phase IV • Over shoot of SBP due to increased venous return and reduced systemic vascular resistance • Followed by reflex bradycardia
  42. 42. • PHASE IV OVERSHOOT PHASE • Murmurs and heart sounds transiently augmented
  43. 43. Square wave response • Seen in • Severe LV dysfunction +_ Heart failure • MS with significant PAH • ASD with significant L to R shunt • Apparently normal persons aged above 55 yr
  44. 44. • Phase I: Intra thoracic pressure rises with increase in sys and pul arterial pressures with no increase in CO • Phase II: ventricular filling is not decreased and venous return is maintained during continued straining. Arterial pressure remains mildly elevated with insignificant changes in PP , HR , LV SV , CO
  45. 45. • Phase III/IV: post release phase pressures return to normal pre strain level • No transient increase invenous return,SV or over shoot BP rise or reflex brady cardia
  46. 46. • The maneuver should be performed with patient in supine position or upper part of body elevated no more than 30 degrees • Strain phase to be limitied to 10 to 12 sec • Should not be performed in patients with active myocardial ischemia or cerebral ischemia and unstable cardiac rhythm
  47. 47. Valsalva Maneuver I/T Pr = VR = BP sympathetic tone HR sudden return of peripherally pooled blood to the vaso-constricted arterial system (20 to the increased sympathetic tone) PHASE II PHASE IV MAXIMAL SYMPATHETIC ACTIVATION FLAT PART OF STARLING’S CURVE HEART FAILURE ASD MS
  48. 48. • Valsalva maneuver is helpful in differentiating rt sided systolic murmurs from those of the left side and of considerable importance in identifying systolic murmur of HOCM
  49. 49. • During strain phase Attenuation of • S3 and S4 • AS & PS • MR & TR • AR & PR • TS & MS • Most of the heart sounds and murmurs decrease in the strain phase of valsalva
  50. 50. • Up on release of valsalva murmurs on the right side of the heart return to baseline intensity in 2 to 3 cardiac cycles where as left sided murmurs donot return to baseline intensity till 5 to 10 cardiac cycles
  51. 51. • Second heart sound • Normal splitting of S2 narrows during the strain phase of valsalva and widens markedly immedaitely during the release phase • Paradoxical plitting of S2 widens during the strain phase and then becomes more narrow during the release phase
  52. 52. POSTPREMATURE VENTRICULAR CONTRACTIONS Followed by a significant pause • Increase in ventricular filling • Augmentation of cardiac contractility- post extra systolic potentiation • Onset of LV ejection at a lower diastolic pressure
  53. 53. During postpremature beat – augmented are • ESM of AS and PS volume contractility • HOCM contractility-increase dynamic LVOT obstruction increase volume decrease LVOT obstruction net increase gradient
  54. 54. • PSM of MR and of VSD - not altered(relatively little further increase in mitral valve flow or change in the LV-LA gradient) (ventricle has has 2 openings aorta and LA in MR not in AS) • Systolic murmur of papillary muscle dysfunction diminish • Increase in LV size delays systolic click and murmur of MVP (depend mainly on volume)
  55. 55. • Similar auscultatory changes follow prolonged diastolic pauses in AF • After a long R-R interval augmented unchanged AS/PS TOF IHSS VSD TR MR AR
  56. 56. • PR interval variations • When PR interval becomes abnormal atrial contribution to ventricles decrease and the stroke volume falls • Varying atrial contribution will cause significant alteration in ESMs • S1 soft with long PR and loud with short PR
  57. 57. PHARMACOLOGICAL AGENTS AMYL NITRITE INHALATION • Crush ampule in towel • take 3-4 deep breaths over 10 – 15 secs • First 30 secs– Systemic art pressure decrease • 30 to 60 secs– Reflex Tachycardia • > 60 secs - positive inotropic effect, SV, EF, CO,HR and Ejection Velocity • Significant increase in venous return
  58. 58. • S1 augmented • A2 diminished • OS mitral and tricuspid valve become louder • A2 OS interval shortens • RVS3 and LVS3 augmented –rapidity of ventricular filling • LVS3 associated with MR diminished(MR reduced)
  59. 59. Systolic murmurs accentuated are • HOCM • AS • PS • TR • Functional systolic murmurs Increased ventricular contractility and SV
  60. 60. Due fall in systemic arterial pressure murmurs diminished are • PSM of MR • PSM of VSD • EDM of AR • Austin flint murmur • Continuous murmur of PDA • Continuous murmur of AVF
  61. 61. Systolic ejection murmur of TOF diminished • Decrease in arterial pressure • Increase right to left shunt • Decrease blood flow in RVOT
  62. 62. Reduction cardiac size leads to • Early appearance of click and murmur of MVP • Murmur intensity show variable response
  63. 63. Amyl nitrate response useful in distinguishing • Systolic murmur of AS(^)and MR(v) • Systolic murmur of TR(^) and MR(v) • Systolic murmur of PS(^) and TOF(v) • Systolic murmur of PS(^) and VSD(v) • Diastolic murmur of MS(^) and Austin flint(v) • EDM of PR(^) and AR(v)
  64. 64. • In HOCM there an additional and earlier( 5 to 10 after inhaltion) augmentation of murmur due to decrease in LV Vol and sys art pressure with resultant increase in LVOT obstruction • This earlier response helps in differentiating HOCM from valvular AS where murmur augmentation starts 15 to 20sec after inhalation
  65. 65. METHOXAMINE AND PHENYL EPHRINE • Increase systemic arterial pressure • Reflex bradycardia and decreased contractility and COP • Contraindicated in CHF and HTN
  66. 66. • Methoxamine 3-5 mg IV increase arterial pressure by 20-40 mm Hg with in 2-3 min lasting for 30 to 40 min • Phenylephrine 0.5mg IV elevates systolic pressure around 30mm Hg for 3-5min • Phenylephrine preferred due to shorter duration action
  67. 67. • S1 reduced • A2 becomes louder • A2 OS prolonged • S3 and S4 response variable • Click of MVP occurs later and accentuated
  68. 68. Increase in arterial pressures cause following murmurs louder • EDM of AR and Austin Flint murmur • PSM of MR • VSD • TOF • Continuous murmurs of PDA and AVF
  69. 69. • Systolic murmur of HOCM softens(^ LV size) • Click and murmur of MVP delayed(^ LV size) Decrease in COP diminish • ESM of AS • Functional systolic murmurs • MDM of MS
  70. 70. TRANSIENT ARTERIAL OCCLUSION • Transient external compression of both brachial arteries • By bilateral cuff inflation to 20 mm Hg greater than peak systolic pressure • Augments the murmurs of MR, VSD, and AR
  71. 71. MS Inspiration, Sudden standing Dec pulmonary venous return, Reduces LAP • MDM reduced • OS softens • A2-OS gap widen • Three sequential sounds (A2, P2, and OS) may be audible • Exercise ,Squatting ,Amyl Nitrate, isometric hand grip MDM accentuated
  72. 72. • Valsalva maneuver may show square wave response • A2 OS interval directly related to R-R interval
  73. 73. MR • Varies little with respiration Decrease murmur • Sudden standing • Valsalva • Amyl Nitrate Augments the murmur • Squatting • Isometric Exercise
  74. 74. AS Murmur increases on • Post PVC beat • squatting • Lying flat from standing Reduces AS murmur • Valsalva • Standing • Handgrip • Abnormal PR
  75. 75. AR EDM increases on • Expiration • sitting up and leaning forward • Squatting • Isometric exercise • Vasopressors Decreases with • Amyl Nitrate • Valsalva
  76. 76. MVP Murmur and click earlier(intensity decreases) LV Volume decrease • Standing • Valsalva Murmur and click later LV Volume increase • Squatting • Post ectopic • Isometric Exercise (intensity increases)
  77. 77. HOCM Increase murmur in • Expiration • Valsalva strain • Standing • Post ectopic • Amyl nitrate Decrease murmur in • Inspiration • Sustained Handgrip • squatting • Methoxamine
  78. 78. • Valsalva strain following amyl nitrate in HCM • In 20 to 30% of patients systolic murmur of HCM remains unchanged after valsalva strain • When valsalva strain is repeated after amyl nitrate inhalation most of these pts will now show augmentation • This maneuver increases the sensitivity of valsalva for diagnosing HOCM
  79. 79. Dynamic auscultation helpful in • AS X HOCM squatting (^/v) valsalva/standing (v/^) • AS x MR handgrip (v/^) phenyl ephrine (v/^) post pvc (^/v) amyl nitrate (^/v)
  80. 80. • MS X TS respiration • MR X TR respiration • MS X AUSTIN FLINT amyl nitrate(^/v) • PS X AS respiration • PS X Small VSD amyl nitrate (^/v) phynylephrine (v/^) respiration • PR X AR squatting (_/^) sus handgrip (-/^)
  81. 81. •Thank you