CARDIAC DIAGNOSTIC ASSESSMENT | 10 | Cardiology | David Laflamme

ABSTRACT

CUTANEOUS INSPECTION: Cyanosis (central vs peripheral); Pallor; Telangiectasias (OslerWeber-Rendu; scleroderma); Tanned skin (hemochromatosis); Jaundice (liver disease); Ecchymoses (coagulopathy); Petechiae (thrombocytopenia); Purpura (vasculitis; endocarditis); characteristic axillary skin fold (pseudoxanthoma elasticum); Lentiginosis (LEOPARD; Carney); Lupus pernio - erythema nodosum (sarcoidosis); blue sclera (osteogenesis imperfecta); nicotine stains (smoking) › Familial hypercholesterolemia: Arcus senilis; pathognomonic tendinous xanthomas (extensor tendons; MCP; Achilles tendon); Xanthelasma › Familial hypertriglyceridemia (LPL deficiency): Eruptive xanthomas; Lipemia retinalis › Dysbetalipoproteinemia: Tuberous xanthomas (elbows; knees); Palmar xanthomas

FUNDOSCOPY: hypertensive retinopathy (arteriovenous nicking; exudates; hemorrhages; cottonwool spots; papilledema); diabetic retinopathy; endocarditis (Roth’s spot); Hollenhorst plaque (cholesterol embolism); Lipemia retinalis

VITAL SIGNS BLOOD PRESSURE: in both arms (± legs) › Large pulse pressure (> 50% of SBP): Age - HTN; AR; Patent ductus arteriosus; Ruptured aneu-rysm of the sinus of Valsalva; Fever; Anemia; Hyperthyroidism; Pregnancy; AV fistula; Paget’s disease › Narrow pulse pressure (< 25% of SBP): Cardiac tamponade; Heart failure; Cardiogenic shock; Aortic stenosis › BP difference between the two arms > 10 mmHg: Normal variant; PAD; Inflammatory vascular disease (Takayasu; giant cell arteritis); Supravalvular aortic stenosis; CoA; Aortic dissection › BP difference between the arms and legs > 20 mmHg: Hill’s sign (significant AR); CoA; severe PAD › Pulsus paradoxus: H SBP > 10 mmHg on inspiration › Orthostatic hypotension: H SBP > 20 mmHg or H DBP > 10 mmHg during the first 3 minutes after standing up › Valsalva response

Ca rd

ia c

di ag

no st

ic a

ss es

sm en

OTHER VITAL SIGNS: Pulse; heart rate regularity; Respiratory rate; Oxygen saturation; Temperature; Weight; Height; Waist › Body surface area (m²) = 0.007184 x weight (kg) x height (cm)

NECK CAROTID PULSE › Shape: g Hemodynamic assessment (arterial recording) › Carotid sinus massage: abnormal response if asystole > 3 seconds (sinus arrest or AV block) and/or significant and symptomatic fall in SBP

JUGULAR VEINS › Jugular vein vs carotid artery: Biphasic; Height modified by inspiration and position and hepatojugular reflux (HJR); Impalpable; Compressible › Height: distance between the sternal angle and the summit of venous pulsation; normal < 3 cmH2O • CVP (cmH2O): height above the sternal angle + 5 cmH2O • Normal CVP: < 8 cmH2O (< 6 mmHg) • Conversion: 1.36 cmH2O = 1 mmHg › Waves: g Hemodynamic assessment (atrial recording)

› Kussmaul’s sign: inspiratory increase (or absence of decrease) of CVP (constriction; RCM; RV infarction; pulmonary embolism; TS; RA tumor; right heart failure) › Hepatojugular reflux (HJR): Right upper quadrant (RUQ) compression (25 mmHg) x 15 seconds • Abnormal response: sustained G of CVP > 3 cm throughout compression (patient breathing normally); reflects right heart failure and/or wedge pressure > 15 mmHg

Normal pattern a wave > v wave

Constrictive pericarditis Predominant y descent / W (or M) pattern

Tricuspid stenosis (or RVH) Predominant a wave

Tricuspid regurgitation Predominant v wave

a a

x x

v v

y x y x yy

a a

x x

y y

a a

x x

v v

y x y x yy

a a

x x

y y

a a

Ca rd

ia c

di ag

no st

ic a

ss es

sm en

INSPECTION OF THE PRECORDIUM: position and dimensions of the apical impulse PALPATION: patient in 30° supine position › Apical impulse: with the fingertips; left lateral supine position as required; medial to the midclavicular line; 4th or 5th intercostal space; diameter < 2 cm • Apical pulsation: corresponds to isovolumic contraction of the LV • Hyperdynamic apex: increased amplitude of apical impulse but of normal duration; AR; patent ductus arteriosus; MR; VSD; hyperthyroidism; anemia; pregnancy • Sustained apical impulse: the impulse persists during or after the carotid upstroke; associated with pressure overload (AS; HCM; HTN) • Enlarged apical impulse: dilatation > 2 cm and/or shift downwards and to the left; associated with LV volume overload • Palpable S3: LV volume overload • Palpable S4: noncompliant LV / G end-diastolic pressure • Triple apical impulse: HCM (early-systole; end-systole due to dynamic LVOT obstruction; S4) › Ectopic pulsation: LV aneurysm (mid-precordial or anterior axillary) › Left parasternal heave: associated with RVH › Thrill: palpate the 4 areas (palm of the hand at the level of the MCP joints) › Pulsation in the 2nd right intercostal space: ascending aortic aneurysm › Pulsation in the 2nd left intercostal space: PA dilatation

LOOK FOR: S1; Ejection click; Mid-systolic click; S2 S1: M1-T1 (interval: 20-30 ms); maximum at the apex; T1 mainly in the 5th left intercostal space; precedes the carotid upstroke

S3S4 Ejection click

x descent

Carotid upstroke

Apical impulse

y descent a c v

Ca rd

ia c

di ag

no st

ic a

ss es

sm en

› G Intensity of S1 (S1 ≥ S2 in the 2nd left intercostal space): Rheumatic MS (early stage); Hyperdynamic state (G dP/dt); PR < 120 ms; G flow through mitral valve (VSD; patent ductus arteriosus) › H Intensity of S1: Calcified MS (H mobility); Systolic dysfunction; PR > 200 ms; acute AR › Variable intensity of S1: AF; AV dissociation; Tamponade › Split S1 (split sound in the 5th left intercostal space): RBBB; ASD (delayed T1); ST (delayed T1); Ebstein’s anomaly

S2: A2-P2; maximum in the 2nd left intercostal space › Normal physiological splitting: on inspiration; 2nd left intercostal space; interval: 20-60 ms

› Normal but narrow inspiratory splitting: PHT (associated with G P2) › Increased splitting: RBBB; severe MR (early A2); VSD (early A2); RVOT obstruction (late P2) › Fixed splitting (A2-P2 variation < 20 msec): ASD; right heart failure (absence of variation of ejection volume according to RV preload) › Paradoxical splitting: LBBB; RV PPM; AS; HCM; LV systolic dysfunction; AR (prolonged ejection)

› G intensity of A2: HTN; CoA; Ascending aortic aneurysm; Transposition of the great arteries; supravalvular AS › H intensity of A2: Valvular AS; AR › G intensity of P2: P2 > A2 in the 2nd left intercostal space or P2 heard at the apex or palpable P2; PHT; Supravalvular RVOT obstruction › H intensity of P2: Valvular PS; pulmonary regurgitation (except if secondary to PHT); Transposition of the great arteries › Single S2: H A2 (AS) or H P2 (PS); Transposition of the great arteries

VALVULAR EJECTION CLICK: coincides with carotid upstroke (120-140 ms after QRS); high-pitched sound; diffuse radiation; best heard in lower left parasternal region; associated with bicuspid aortic valve (valve still pliable) or congenital PS (H click on inspiration; valve still pliable) › Vascular ejection click: Aortic root dilatation; PA dilatation (idiopathic; post-stenotic; PHT)

EXPIRATION

INSPIRATION

S1 S2

M1-T1 A2-P2

M1-T1 A2 P2

EXPIRATION

INSPIRATION

S1 S2

M1-T1 P2 A2

M1-T1 P2-A2

Late A2

EXPIRATION

INSPIRATION

S1 S2

M1-T1 A2-P2

M1-T1 A2 P2

EXPIRATION

INSPIRATION

S1 S2

M1-T1 P2 A2

M1-T1 P2-A2

Late A2

Ca rd

ia c

di ag

no st

ic a

ss es

sm en

MITRAL OPENING SNAP: High-pitched sound; stethoscope diaphragm at the apex; A2-opening snap interval inversely proportional to the severity of MS (40-120 ms after S2); interval decreases with tachycardia; H intensity of opening snap when the valve is calcified

S3: left lateral supine position; stethoscope bell at the apex; 140-160 ms after S2; during rapid ventricular filling (at the end of the y descent); associated with ventricular volume overload › Etiologies: Dilated cardiomyopathy; heart failure; MR; AR; VSD; patent ductus arteriosus; diastolic dysfunction; young subjects in good health; normal pregnancy › Right S3: lower left parasternal region; G on inspiration; TR; right heart failure; PHT

S4: left lateral supine position; stethoscope bell at the apex; occurs during atrial kick (after the P wave); associated with a poorly compliant ventricle and G filling pressure › Etiologies: HTN; AS; HCM; LVH; Ischemia; Acute AR; Acute MR; Age › Right S4: lower left parasternal region; G on inspiration; RVOT obstruction; PHT

IDENTIFY: Moment of the cycle; Configuration (crescendo; decrescendo; crescendodecrescendo; plateau); Site; Radiation; Tone; Intensity; Modifiers (breathing; special maneuvers) › 1/6: Very faint murmur (barely perceptible) › 2/6: Faint murmur but heard immediately › 3/6: Moderate murmur › 4/6: Palpable thrill › 5/6: Very loud; heard even when only part of the stethoscope is in contact with the chest › 6/6: Heard even when the stethoscope is not in contact with the chest

BENIGN MURMUR: 1-2/6 in left parasternal region; Ejection murmur; S2 of normal intensity with normal physiological splitting; No other heart sounds or murmurs; No LVH (on examination or ECG); Murmur not increased by Valsalva maneuver or standing

INDICATIONS FOR TTE: Diastolic or continuous or holosystolic or end-systolic or early systolic murmur or associated with ejection click or ≥ 3/6 with mid-systolic peak or radiating to the neck or back or signs or suspicion of MR, MVP, HCM or VSD on dynamic auscultation

SYSTOLIC MURMUR Mid-systolic (often diamond-shaped)

• Benign • Ejection murmur: High output state (pregnancy; hyperthyroidism; anemia; AV fistula; AR; PR; ASD) • Aortic stenosis (supravalvular; valvular; subvalvular) • Aortic sclerosis • HCM • PS (supravalvular; valvular; subvalvular) • CoA • Functional / ischemic MR

S1 S2

S2 S1

S1 S2

Ca rd

ia c

di ag

no st

ic a

ss es

sm en

Holosystolic

• MR • TR • VSD (restrictive)

Early systolic • Acute MR • Primary TR (without PHT) • VSD: small muscular VSD or large VSD with significant PHT

End-systolic

• MVP • Functional / ischemic MR (G on exercise) • Tricuspid valve prolapse

• AR • Graham-Steell: PR secondary to PHT (decrescendo; high-pitched; signs of associated PHT) • PR without PHT (faint murmur)

Mid-diastolic • MS • TS • Austin-Flint (absence of opening snap) • Myxoma • G diastolic flow through AV valve (MR; TR; VSD; patent ductus arteriosus; ASD; abnormal pulmonary venous return) • Carey Coombs murmur (mitral valvulitis during acute rheumatic fever)

End-diastolic • MS (presystolic accentuation) • TS • Austin-Flint • Myxoma • Rytand’s murmur: diastolic mitral regurgitation in a context of complete AV block

CONTINUOUS MURMUR (OFTEN PATHOLOGICAL) Starts at systole and continues uninterrupted during diastole

• Patent ductus arteriosus (Gibson’s murmur; machinery murmur) • Aortopulmonary window • Coronary arteriovenous fistula • Ruptured aneurysm of the sinus of Valsalva • Neck venous hum • Mammary murmur of pregnancy • Stenosis of peripheral branch of pulmonary artery • Lutembacher’s syndrome: MS + ASD • CoA / Intercostal collateral vessels • Pulmonary or systemic AV fistula • Bronchial collateral vessels

S1 S2

S2 S1

S1 S2 S1

S1 S2

S2 S1

S1 S2 S1

S1 S2

S2 S1

S1 S2 S1

S1 S2

S2 S1

S1 S2 S1

S1 S2

S2 S1

S1 S2 S1

S1 S2

S2 S1

S1 S2

S2 S1

S1 S2 S1

Ca rd

ia c

di ag

no st

ic a

ss es

sm en

MANEUVERS AS HCM MVP MR OTHER

Valsalva (H preload)

Standing up (H preload)

Squatting or leg raising (G preload)

Hand grip (G afterload)

unchanged or H

Amyl nitrate (H afterload)

Post-PVC (G contractility)

unchanged

LOWER LIMBS: murmurs; lower limb edema; pulse in both legs; capillary refill; discoloration; ulcer; coldness; atrophic changes; hair loss › Radiofemoral delay: CoA › Pulse: 0 = absent; 1 = decreased; 2 = normal; 3 = bounding BRIEF NEUROLOGICAL EXAMINATION

Ca rd

ia c

di ag

no st

ic a

ss es

sm en

NORMAL VALUES

Calibration • Vertical: 10 mm = 1 mV • Horizontal: 1 mm = 40 msec

P wave duration and amplitude < 120 ms and < 2.5 mm in amplitude

P wave axis 60° (positive I-II-aVL-aVF; negative aVR) Normal axis: 0-90°

PR interval 120-200 ms

QRS duration ≤ 110 ms

QRS axis -30° to +90°

Precordial QRS transition R = S in V3 or V4

QRS amplitude • Limbs: > 5 mm • Precordial: > 10 mm

J Point / ST segment

Elevation • V2-V3: < 2 mm (men > 40 years); < 2.5 mm (men < 40 years); < 1.5 mm (women) • Other leads: < 1 mm Depression: < 0.5 mm

T wave

• Positive: I-II-V3-V4-V5-V6 › V5-V6: T wave inversion < 1 mm in 2% • Negative: aVR • Variable: aVL-III-V1-V2 • Maximum amplitude V2: < 14 mm (men) and 10 mm (women)

QTc • Men: < 450 ms • Women: < 460 ms

PR interval

QT interval

QRS interval

Ca rd

ia c

di ag

no st

ic a

ss es

sm en

SINUS RHYTHM (SR): origin of sinoatrial node; HR 60 -100 bpm › Sinus tachycardia: HR > 100 bpm › Sinus bradycardia: HR < 60 bpm › Normal atrial activation: RA to AV node and to LA; P axis 0° to +90° (positive P wave I-II-aVL-aVF); biphasic P wave in V1-V2; duration < 120 ms › Retrograde atrial activation: retrograde AV conduction or ectopic atrial pacemaker close to AV node; negative P wave in II and aVF

aVF

Ca rd

ia c

di ag

no st

ic a

ss es

sm en

› Abnormal activation: RA activation A Bachmann’s bundle block A LA activation from coronary sinus (from inferior to superior)

X:Y AV CONDUCTION: failure of AV node to conduct certain atrial impulses to the ventricle; the refractory period of the AV node is longer when it is stimulated more rapidly (decremental conduction)

› AV block with variable conduction: 2:1 3:1...; frequent in atrial flutter

AV DISSOCIATION: independent atrial and ventricular rhythms; 3 situations: 1) 3rd degree AV block; RR interval > PP interval 2) Accelerated junctional rhythm or junctional tachycardia or VT (without retrograde VA conduction); RR < PP; ± fusion or capture beats 3) Sinus bradycardia with junctional or ventricular escape (without retrograde VA conduction); RR < PP; ± isorhythmic dissociation

• Axis 60° • Duration < 120 ms

> 2.5 mm

> 1.5 mm

> 120 ms

> 40 ms

> 60 ms

> 1 mm

Peaked P wave

• Axis > 75° • Axis terminal portion -30° to -90° (negative in III)

Ca rd

ia c

di ag

no st

ic a

ss es

sm en

Normal axis -30° to + 90°

I + aVF + (if aVF - AII +)

Right axis deviation

+90° to +180°

I - aVF +

DDx: RVH; LPHB; dextrocardia; lateral infarction; secundum ASD; vertical heart (COPD); pulmonary embolism

Left axis deviation

-30° to -90°

I + aVF -

and II -

DDx: LVH; LAHB; primum ASD; complete AV canal defect; Tricuspid atresia (under-developed RV); pregnancy; ascites; inferior infarction

Extreme “North-West” axis deviation

- 90° to 180°

I - aVF -

QRS: INTRAVENTRICULAR CONDUCTION ABERRANT CONDUCTION OF SUPRAVENTRICULAR BEATS: arrival of a supraventricular beat during the relative refractory period of intraventricular conduction tissue; conduction with wide QRS (RBBB > LBBB morphology)

Refractory period of right bundle branch

Ca rd

ia c

di ag

no st

ic a

ss es

sm en

ASHMAN PHENOMENON: Long RR then short RR A wide QRS (frequent RBBB morphology); long RR associated with G refractory period of His-Purkinje tissue

LAHB (LEFT ANTERIOR HEMIBLOCK) 1) Left axis deviation -45° to -90° 2) qR in I and aVL 3) rS in III and aVF 4)QRS duration < 120 ms 5) R wave peak time in aVL > 45 ms › Late precordial QRS transition › Rule out differential diagnoses: LVH; COPD; inferior infarction

LPHB (LEFT POSTERIOR HEMIBLOCK) 1) Right axis deviation +90° to +180° 2) rS in I and aVL 3) qR in III and aVF 4) QRS duration < 120 ms › Rule out differential diagnoses: RVH; COPD; lateral infarction; dextrocardia; arm lead reversal

LAHB LPHB

I - aVL III - aVF I - aVL III - aVF

LBBB (LEFT BUNDLE BRANCH BLOCK) 1) QRS ≥ 120 ms 2) Wide monophasic R wave in I-aVL-V5-V6 3) Absence of septal q wave in I-V5-V6 4)R wave peak time > 60 ms in V5-V6 5) ST and T in opposite direction to QRS (appropriate discordance)

Acute myocardial infarction with a LBBB (Sgarbossa criteria)

1) ST elevation ≥ 1 mm in leads with positive QRS (inappropriate concordance) 2) ST depression ≥ 1 mm V1-V2-V3 (inappropriate concordance) 3) ST elevation ≥ 5 mm in leads with negative QRS (extreme discordance)

Old myocardial infarction in LBBB

1) Cabrera’s sign: Notch of the upslope of the S wave in V2-V3-V4 2) Chapman’s sign: Notch of the upslope of the R wave in V5-V6-I-aVL

aVL: R wave peak time > 45 ms

Ca rd

ia c

di ag

no st

ic a

ss es

sm en

INCOMPLETE LEFT BUNDLE BRANCH BLOCK 1) QRS 110-119 ms 2) LVH pattern 3) R wave peak time > 60 ms in V5-V6 4)Absence of septal q wave in I-V5-V6

RBBB (RIGHT BUNDLE BRANCH BLOCK) 1) QRS ≥ 120 ms 3) rsr’, rsR’, or rSR’ in V1 or V2 (width of R’ or r’ > width of r) 4) S > 40 ms in I and V6 (S larger than R in V6) › In a minority of patients, wide monophasic R wave in V1 and/or V2 (with R wave peak time > 50 ms in V1) › If axis deviation: consider bifascicular block (RBBB with LAHB or RBBB with LPHB) › If bifascicular block with G PR: consider lesion of 3 branches with prolonged HV interval

INCOMPLETE RIGHT BUNDLE BRANCH BLOCK 1) QRS 110-119 ms 2) Other criteria similar to RBBB

NONSPECIFIC INTRAVENTRICULAR CONDUCTION DISORDER 1) QRS > 110 ms 2) Absence of criteria of RBBB or LBBB

VENTRICULAR PRE-EXCITATION 1) PR interval < 120 ms (in sinus rhythm) 2) Delta Wave: slow rise of the initial portion of the QRS 3) QRS ≥ 120 ms 4) Secondary ST and T anomalies › Possible pseudo-infarction (Q waves) › Concertina effect: the degree of pre-excitation can vary according to conduction and the refractory period of the accessory pathway and AV node

QRS >120 ms

I and V6 : S ≥ 40 ms

Deep S wave

r wave < 30 ms or absent

rsr` or rsR` or rSR`

R wave peak time > 60 ms

Prominent wide R wave

Absence of septal Q wave

Ca rd

ia c

di ag

no st

ic a

ss es

sm en

SITE OF ACCESSORY PATHWAY V1 aVF aVL

Left lateral + + -

Posterior or left septal + - +

Posterior or right septal - - +

Anterior or right lateral - + +

QRS: PRECORDIAL R WAVE TRANSITION NORMAL VENTRICULAR ACTIVATION: 1) Left-to-right septal activation (septal q wave in I-aVL-V5-V6; septal r wave in aVR and V1; 2) Anterior LV then lateral LV activation; 3) Posterobasal LV activation

NORMAL PRECORDIAL TRANSITION: rS V1 A qR V6; R = S in V3 or V4 › DDx of abnormal precordial transition: lead malposition; dextrocardia; anterior or anteroseptal or posterior myocardial infarction; LVH; RVH; LAHB; LBBB; RBBB; dilated or infiltrative cardiomyopathy; pre-excitation (right or anteroseptal accessory pathway); COPD; pneumothorax; chest wall anomaly...