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and refinement, easily accomplished, for exam- atelectasis” the senior mumbled as we gathered
to see the man.
ple, by correlating echocardiography results with
His heart rate was regular at 102 bpm with a BP
bedside findings. Medical imaging is most pow- of 156/72 mmHg. He felt warm and had a brisk
erful within an accurate clinical context, where carotid upstroke with collapsing pulses. Palpation
specific questions like “how severe is the aortic of his precordium revealed a hyperdynamic
insufficiency (AI)” are posed, rather than vague- normally placed apical impulse, palpable medial
to the midclavicular line with only one finger.
ly asking, “is any structural heart disease pre-
Auscultation revealed soft first and second heart
sent?” Otherwise, we relegate our high technol- sounds with a left-sided third heart sound. As
ogy to rambling and expensive diagnostic “fish- well, at the base of the heart there is a grade 2/6
ing trips.” If we neglect our role as clinicians, early-peaking crescendo-decrescendo systolic
facile with the art of physical examination, our murmur that radiated to both clavicles and
extended along the left sternal border, unchanged
proud medical profession becomes reduced to a with either Valsalva maneuver or handgrip. The
technical vocation and the patient gets lost in the remainder of his cardiovascular exam was
shuffle of lab results and imaging reports. unremarkable with the patient in the supine
position.
The presence of a diastolic murmur always
signifies cardiac pathology. Unlike systolic flow
murmurs that can occur in healthy hearts, What is causing the murmur and might it affect
his management? Turn to page 45 to find out...
diastolic murmurs are never benign.
Unfortunately, diastolic murmurs can be
Clues from the vital signs the diastolic pressure reduced because of the
baroreceptor-induced peripheral vasodilation and
The first clues to the presence of diastolic diastolic run-off. The pulse pressure increases as
pathology lie in heart rate and BP determination. the pulse wave moves further from the heart,
Legend has it that Sir William Osler diagnosed a being more pronounced in the legs than the arms.
patient with mitral stenosis from the foot of the The ankle-brachial index can offer a measure of
bed by palpating the patient’s big toe. Lucky AI severity, known as Hill’s sign (a palpatory
guess? It would certainly seem so, but consider- ankle systolic BP which is 20 mmHg greater than
ing that rheumatic valve pathology was the lead- a simultaneously measured brachial palpatory
ing cause of heart disease in his day, and that atri- systolic BP), although some investigators feel
al fibrillation (AF), also known as pulsus mitrale, that its’ value has been overstated.2 Generally the
was commonly found in those with significant more marked the pulse pressure, the more severe
mitral stenosis, it was more likely an educated the chronic AI with some caveats. The systolic
guess. I would not try this on ward rounds since accentuation in AI becomes more pronounced
the finding of an irregular pulse today is not spe- with aging as the vasculature loses its elastic
cific for mitral stenosis. Nonetheless, the pres- recoil capacity. As well, coexistent hypertension
ence of AF in patients with valvular heart disease can maintain a normal or even high diastolic
is a useful indicator of increasing severity. pressure despite significant AI.
The pulse pressure, measured as the differ-
ence between systolic and diastolic readings, can
Clues from the carotid pulse
offer a valuable clue to the presence of signifi- As a central pulse, inches from the heart, the
cant AI. A widened pulse pressure, defined as carotid upstroke and volume can provide critical
> 50% of the systolic pressure, occurs with information regarding cardiac hemodynamics
chronic significant AI. The systolic pressure is and should be assessed during every cardiovas-
elevated due to the increased stroke volume and cular examination. Ejection of blood from the
Systolic Murmur
S3 and S4
20 200 1K 20K
Frequency range (Hertz)
left ventricle into the aorta causes systolic the systolic BP and produces a high volume
expansion of the carotid arteries. This is repre- carotid pulsation. When visible to inspection,
sented as the initial slope of the ejection phase of this exaggerated pulsation in the neck is referred
the cardiac cycle (Figure 2). The best technique to as a Corrigan’s pulse, resembling a bullfrog in
to discern this slope is to apply firm pressure extreme cases. Together with a brisk carotid
with your left thumb over the patient’s right upstroke, an increased carotid volume should
carotid pulse. Locate the pulse just medial to the instruct the clinician to think AI.
sternocleidomastoid muscle, at the level of the
thyroid cartilage (Figure 3). A normal carotid
upstroke has a tapping quality and can be refer- Ejection Phase
enced to the examiner’s own carotid pulse. (Carotid Upstroke)
Increased force of myocardial contraction caus-
es the upstroke to be brisk, perceived by the Pulse Pressure
examining thumb as “flicking” on the thumb,
rather than “tapping.” A brisk carotid upstroke Isovolumetric
can occur with any hyperdynamic condition Contraction
including:
Time
• sepsis,
(Apical Impulse)
• anemia,
• pregnancy and Figure 2. Hemodynamics of the cardiac cycle.
• hyperthyroidism.
Cardiac conditions that can produce a brisk
Assessing for a collapsing pulse
carotid upstroke include:
• significant aortic valve regurgitation (AR), A collapsing pulse refers to the slapping sensa-
• mitral insufficiency, tion when holding the tissue of the forearm of a
• hypertrophic obstructive cardiomyopathy patient with significant AI. The large stroke vol-
(HOCM) and ume occurring in AI stretches the left ventricle at
• ventricular septal defect. end-diastole and increases the inotropic ejection
Each of these cardiac conditions can be clinically force by the Starling effect, propelling the
differentiated on the basis of their respective sys- increased volume at high velocity into the aorta.
tolic murmurs.3 When combined with aortic steno- An obscure child’s toy in Victorian England
sis, the large stroke volume of AI causes the carotid secured itself a position in the history books of
artery to vibrate. This phenomenon, termed a carotid medicine when clinicians of the time compared
shudder or bisferiens pulse, is powerful evidence for it to the pulse of AI. The toy was called a water
AI, rendering auscultation almost redundant. hammer and consisted of a glass tube filled part-
The amount of arterial expansion is referred to ly with water or mercury under a vacuum seal.
as the carotid volume and represents the arterial The liquid produced a slapping impact when the
pulse pressure. In significant chronic AI the pulse glass tube was shaken or turned over. This
pressure widens. An incompetent aortic valve colourful analogy has been perpetuated with the
forces the left ventricle to eject not only the left term “water hammer pulse” to denote the col-
atrial blood coming at it, but also the fraction of lapsing pulse of AI. To check for the presence of
stroke volume that has been regurgitated. This a collapsing pulse, grasp the patient’s forearm
now giant stroke volume causes the elevation in firmly with both hands in a clamshell squeeze,
holding the arm first in the horizontal position, best palpate the apical impulse, apply firm pres-
and then raising it passively to the vertical sure over the inframammary region of the pre-
(Figure 4). With severe aortic valve incompe- cordium using the volar aspect of the mid-pha-
tence the slapping impulse can be immediately langes of the right hand, with the patient lying
felt with the arm horizontal. In less severe cases, supine and to the left of the examiner.
the slapping impulse may only become apparent Sometimes palpating the apex with the patient in
when the arm is lifted vertically. Vertical posi- the left lateral decubitus position helps to make
tioning of the arm increases the diastolic run-off it more apparent, since the heart moves closer to
by applying gravity and exaggerates the collaps- the chest wall. The key features of the apical
ing pulse sensation. Other signs representing the impulse include its location, size and duration.
same physiology include Quincke’s nailbed pul- The location and size of the apical impulse
sation and the digital throb, but are less specific are both clinical indicators of heart size. The
and far less valuable. normal apical impulse should measure within
10 cm of the midsternal line (MSL), or medial to
the mid-clavicular line. The “10 cm rule” seems
to hold regardless of patient size, since the larg-
er the patient, the more difficult it is to localize
the most lateral aspect of the impulse. The size
of the apical impulse should be no larger than
the width of two fingertips and palpable in only
a single intercostal space. If three fingertips can
palpate the apex or if it is palpable in two sepa-
rate intercostal spaces, then the impulse is dif-
fuse and the heart is likely enlarged. If left
untreated, severe AI can lead to massive left ven-
tricular enlargement, referred to as cor bovinium
or cow heart. A diffuse and deviated apical
Figure 3. Carotid artery palpation. impulse gives a clue to volume overload and fits
with severe chronic AI.
In mitral stenosis, the left ventricle is protect-
Clues form the apical impulse ed by the stenotic mitral valve, maintaining a
The apical impulse is defined as the most infer- normal apical size and location. However, the
olateral palpable precordial impulse and repre- fibrocalcified rheumatic mitral valve can close
sents the isovolumetric contraction time (IVCT) with such force that it may be palpable at the
of the cardiac cycle (Figure 2). During this por- apex when the patient is in the left lateral decu-
tion of the cardiac cycle, the left ventricle con- bitus position. A palpable S1 feels like a tran-
tains its full blood volume, the ventricular walls sient flicking sensation superimposed onto the
thicken and the heart rotates in a counter clock- pushing of the apical impulse and should pique
wise rotation (as seen from below, looking ones’ interest in assessing the intensity of the
upwards). This allows the apex of the heart to first heart sound by auscultation.
come into transient contact with the chest wall,
before the aortic and pulmonary valves open. To
Stethoscope positioning
To amplify the high frequency murmur of AI,
use the diaphragm of the stethoscope over the
lower left sternal border. Press firmly enough to
leave an imprint on the skin to damp out low
frequencies and unmask the high frequencies.
Handgrip increases peripheral vascular
resistance which amplifies aortic
By contrast, since mitral stenosis is a low fre-
insufficiency murmur quency murmur, use the bell of the stethoscope. The
bell works by making use of the loose underlying
Figure 5. Handgrip maneuver. skin of the patient as the membrane to collect sound
from the chest wall and transmit it to the stethoscope
Amplifying the diastolic murmur tubing.4 If undo pressure is applied to the bell, the
underlying skin becomes taught which tends to
If the clues point to diastolic pathology, the chal- damp out the desirable low frequencies. Holding the
lenge remains to bring out the murmur. To best hear stethoscope by the tubing rather than with the bell,
a diastolic murmur one has to do some prep work: with just enough pressure to prevent room-noise
• positioning the patient, leak, will give best results. As well, locating the apex
• adjusting the stethoscope and is important since the diastolic rumble of mitral
• applying dynamic maneuvers. stenosis is often only heard directly over the palpa-
The boy scouts’ adage of being prepared goes a ble apical impulse, disappearing even if only cen-
long way in exposing a hidden diastolic murmur. timetres away.
A B