Cardiac Auscultation.pptx

Cardiac Auscultation Health Assessment Goals of Cardiac Evaluation Identify severity of cardiac disease Identify degree of impaired myocardial contractility Identify other organ involvement Kidneys Liver Brain Pancreas Functional Assessment Cardiac Auscultation Starts with an interview All patients...

Cardiac Auscultation Health Assessment Goals of Cardiac Evaluation Identify severity of cardiac disease Identify degree of impaired myocardial contractility Identify other organ involvement Kidneys Liver Brain Pancreas Functional Assessment Cardiac Auscultation Starts with an interview All patients need to have their heart and lungs auscultated – always. Cardiac auscultation helps identify: Valvular heart disease Heart failure Dysrhythmias Presence of clinically significant v. insignificant murmurs Heart Valves Heart Murmurs Grade Description I Faintest murmurs that can be heard with difficulty II Faint but easily heard III Moderately loud without a thrill IV Loud with a palpable thrill V Loudest murmur requiring a stethoscope & thrill VI Heard without a stethoscope Phonocardiograms Mitral Stenosis Most common cause  rheumatic fever Females > Males Diffuse thickening of leaflets, calcification of annulus Slow process (20-30 years) Eventually develop CHF Pulmonary hypertension RV failure Symptoms are precipitated by pregnancy or illness Mitral Stenosis Symptoms elicited on interview (related to elevated LA pressure) DOE Orthopnea PND AF (dilated LA) Diastolic murmur Normal orifice is 4-6 cm2 Symptoms develop at about 1.5 cm2 Severe/critical disease 0.6-1.0 cm2 Transvalvular gradient of 10 mmHg Mitral Stenosis Early- to mid-diastolic murmur at the apex Opening snap, low-pitched rumble radiating to axilla Findings would warrant further workup: Gold standard is an echo Looking for valve area, LV function, transvalvular pressure gradient, pulmonary hypertension Evaluated with an EKG as well POCUS Findings: classic sign is “doming” of anterior valve leaflet Mitral Regurgitation Associated with MS if rheumatic in origin If isolated MR, assume ischemic disease until proven otherwise Can be ruptured chordae tendineae Decreased forward LV stroke volume and CO Portion of every stroke volume regurgitated through incompetent mitral valve back into LA Mitral Regurgitation Insidious progression, symptoms often not elicited or are nonspecific Long term enlargement of LV to compensate Compensation of increase LA compliance/LVH accommodate increased volume If acute rupture  pulmonary edema/cardiogenic shock Mitral Regurgitation Holosystolic murmur at apex High pitched, blowing, loud S3 radiating to axilla Cardiomegaly on physical exam or CXR EKG changes: LA/LV enlargement Gold standard is echo LA size, pressure LV wall thickness LV function Cardiac cath if severity cannot be confirmed Mitral Valve Prolapse Leaflets prolapse back into LA with or without MR (during systole) Most common lesion, 1-2.5% of population Associated with: Marfan’s Syndrome, rheumatic carditis, myocarditis, lupus Usually benign BUT  CVA (embolic), dysrhythmias Mitral Valve Prolapse Mid- to late-systolic click and late-systolic murmur Crescendo Symptoms include anxiety, orthostatic hypotension, palpitations, dyspnea, fatigue, and atypical chest pain Echo to determine degree of prolapse and associated LV involvement Functional v. pathologic disease Aortic Stenosis Most common valvular lesion in the US Degeneration and calcification of leaflets (aging) Bicuspid v. tricuspid valve (congenital, younger) Associated with risk factors similar to ischemic heart disease Symptoms Angina (without CAD), syncope, CHF 75% of patients with symptoms die within 3 years without replacement Aortic Stenosis Mid-systolic murmur in 2nd right and left parasternal spaces Crescendo-decrescendo diamond pattern, radiates to carotid(s), S3 and S4 if significant Contour of diamond relates to severity of pressure gradient across valve MANY PATIENTS ARE ASYMPTOMATIC, so ALL old people are at risk until ruled out Aortic Stenosis EKG may show LVH Echo to determine: Valve morphology LV function Aortic valve area & pressure gradient measurements Cardiac cath may be necessary if echo is not diagnostic Symptoms when pressure 25-40 mmHg & valve area