Physical Exam 101: Differentiating HOCM from AS from Chronic MR

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Physical Exam 101 Differentiating HOCM from AS
from Chronic MR

• Daniel J. ORourke, MD
• Veterans Affairs Hospital
• Dartmouth-Hitchcock

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Valvular Abnormality

• Cardiovascular Exam
• JVP Pressure Pulsations
• Carotid Pulse Rate, Rhythm, Rate of rise,
  Volume, Compliance
• Inspection precordial pulsations
• Palpation LV apical impulse, Thrills, and
  Heaves
• Heart Sounds ? Intensity 2 components
  to S1 and S2 Gallops S3 or S4
• Murmur

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Evaluation of Murmurs

• Systolic or Diastolic
• Intensity (Loudness) - Grade I-VI
• Location
• Pitch (high diaphragm low - bell)
• Quality (blowing, harsh, musical)
• Duration
• Radiation

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Pathologic vs. Nonpathologic Murmurs

• Always pathologic if
• Diastolic murmur
• Holosystolic or late systolic murmur
• Continuous murmur
• Grade 4-6 murmurs
• Concomitant cardiac symptoms or exam findings

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JACC 1998321486-1588.
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Hypertrophic Cardiomyopathy

• Autosomal dominant - variable phenotypic
  expression
• 1500 in the general population
• Disease of the sarcomere
• Patterns of hypertrophy localized, concentric,
  apical
• Two forms
• Obstructive 25
• Nonobstructive 75

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Obstructive Form - HOCM

• Asymmetric septal hypertrophy (ASH)
• Systolic anterior motion (SAM) of the anterior
  mitral leaflet
• Degree of SAM correlates with the severity of the
  MR
• (30-50 have concomitant MR)

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HOCM Px Exam Findings

• JVP
• Normal venous pressure
• Large A wave on JVP ? elevated RVEDP
• Carotid
• Brisk, sometimes jerky, carotid upstroke ? taps
  against the fingers
• Palpation
• Sustained, forceful LV apical impulse with a late
  heave - Palpable S4
• May be a thrill ? suggests LVOT obstruction
• Heart Sounds
• Normal S1 and S2. (Severe LVOT obstruction -
  paradoxical S2).
• Loud S4 gallop is the rule!

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HOCM Px Exam Findings

• Murmurs
• Harsh midsystolic murmur at the LLSB and apex.
  Variable duration and intensity.
• Holosystolic apical murmur that tapers in late
  systole.
• Maneuvers
• Valsalva decreases preload increased murmur
  intensity
• Standing decreases preload increased murmur
  intensity
• Squatting increases preload decreased murmur
  intensity

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Aortic Stenosis

• Two common causes
• Congenital and Degenerative (calcific)
• Findings
• Diminished carotid upstroke
• Harsh, raspy, sometimes honking SEM at the base
• Radiates to the carotids and/or apex
  (Gallavardin)
• Intensity of murmur decreases with Valsalva.
• Clues to assessing severity
• Carotid upstroke
• Duration of the murmur
• Splitting of S2

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Assessing AS Severity by Exam

• Splitting of S2
• Physiologic --gt Mild
• Single --gt Mod/Severe
• Paradoxical --gt Severe

• Murmur Peak
• Early-mid --gt Mild
• Mid-late --gt Moderate
• Late --gt Severe

Sustained LV apical impulse, S4 gallop Moderate
to severe
Delayed, diminished carotid upstroke - Severe
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Chronic Mitral Regurgitation

• Pathophysiologic mechanisms
• Annulus
• Mitral valve leaflets
• Chordae tendinae
• Papillary muscles
• Classic murmur
• High pitched, blowing, holosystolic murmur at the
  apex
• Radiates to the axilla or left sternal border

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Assessing MR Severity by Exam

• Mild MR
• Normal carotid upstroke
• Normal LV apical impulse
• Heart Sounds
• Normal intensity of S1
• Grade 1-2 murmur

• Moderate-Severe MR
• Carotid pulse - Brisk upstroke
• Hyperdynamic, displaced LV apical impulse
• Heart Sounds
• Soft S1
• S2 widely split
• S3 gallop

Differentiating feature from HOCM - Absence of an
S4 gallop.
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Conclusions

• HOCM common disease 1500
• Normal JVP with increased A waves
• Brisk carotid upstroke
• Sustained apical impulse concentric hypertrophy
• S4 gallop is the RULE!
• Harsh mid peaking SEM and holosystolic apical
  murmur
• Murmur intensity INCREASES with fall in preload
  (Valsalva, standing)
• Aortic Stenosis
• Diminished carotid upstroke
• Murmur intensity DECREASES with fall in preload
• Chronic MR
• Brisk carotid upstroke
• Inferolaterally displaced LV apical impulse
  eccentric hypertrophy
• Soft S1
• S4 is rare
• S3 is common

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Recommended Reading

• Synopsis of Cardiac Physical Diagnosis. 2nd
  edition. Jonathan Abrams. Butterworth-Heinemann,
  2001.
• Physical Examination of the Heart and
  Circulation. 3rd edition. Joseph K. Perloff.
  W.B. Saunders Company, 2000.