Dynamic auscultation

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DYNAMIC AUSCULTATION

• Altaf Ali Naushad
• PG Trainee

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• 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

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• Interventions most commonly employed are
• Respiration
• Postural changes
• Isometric exercise
• Valsalva maneuver
• Premature ventricular contractions
• Vasoactive agents- amyl nitrite ,methoxamine,
  phenylephrine

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RESPIRATION

• 1)Splitting of S2

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• EXPIRATION
• LVS3 and LVS4
• Mitral OS

• 2)Heart sounds
• Accentuated during
• INSPIRATION
• RVS3 and RVS4
• Tricuspid OS

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• 3)Pulmonary ejection click
• Inspiration diminishes the intensity of valvular
  PEC.
• PA diastolic pressure is very low
• Inspiration causes elevation of RV EDP
• RV late diastolic Pr gt PA Pressure
• Causes partial presystolic opening of PV
• Less upward motion of valve during systole

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• 4)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

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Murmurs accentuated during

• EXPIRATION
• MS
• MR
• AS
• AR
• VSD
• Pericardial rub

• INSPIRATION
• TS, PR (diastolic murmurs)
• TR (Carvallos sign)
• Mild or moderate PS
• Severe PS no further increase in gradient
• Presystolic murmur of Ebsteins anomaly

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• 5)MVP
• MSC and systolic murmur occur earlier during
  systole in inspiration
• Inspiratory reduction in LV size
• Increased redundancy of MV
• Increase valvular prolapse

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• 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.

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• Widens split S2 and augments murmur and filling
  sound originating in right side of the heart.

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POSTURAL CHANGE

• 1)RAPID STANDING
• Decrease in venous return, thus stroke volume.
• Right and left ventricular diastolic volumes and
  stroke volumes decline. Interval of 6-8 cycles,
  between the right side and the left.
• There also may be a fall in arterial pressure and
  a reflex increase in heart rate.

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• Width of the splitting become reduced (P2 moves
  closer to A2)
• No change in patients with true fixed split
• Decrease in intensity
• RVS3 and RVS4
• LVS3 and LVS4

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• Decrease in intensity
• Semilunar valve stenosis
• AV valve regurgitation murmurs
• VSD
• Most functional systolic murmurs

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• Since LV EDV is decreased
• Increase in murmurs
• HOCM(95 sensitivity, 84 specificity)
• Early MSC and murmur of MVP

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• 2)SQUATTING
• Sudden change from standing to squatting position
  
• Increase venous return and systemic resistance
  simultaneously ?abruptly increases ventricular
  preload and afterload.
• Arterial pressure rise may cause transient reflex
  bradycardia

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• Increase in stroke volume causes augmentation of
• S3 and S4(of both ventricles)
• Right sided murmurs
• MS
• AS

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• Elevation of arterial pressure (afterload)
• Increase in aortic reflux AR Austin Flint murmur
  may also be increased.
• Increase in MR volume
• Increase in Lt ? Rt shunt in VSD
• Increase in blood flow through RVOT in TOF

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• 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 ? there is a
  delay in prolapse of mitral valve induced by
  increased preload, due to the increased
  afterload. Redudandancy of MV also reduced.

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• In patients with tetralogy of Fallot, the net
  effect of squatting is usually an increase in
  pulmonary flow, which is associated with
  increased intensity of the pulmonary ejection
  systolic murmur. 
• Squatting increases peripheral vascular
  resistance and thus decreases the magnitude of
  the right-to-left shunt across the VSD. 

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• 3)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

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• 4)SITTING AND LEANING FORWARD
• Accentuate AR and PR murmur (mechanical)

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ISOMETRIC EXERCISE

• This can be carried out by using a calibrated
  handgrip device or a handball
• Better to carry out bilaterally
• Should be sustained for 20 to 30 secs
• Valsalva maneuver during the handgrip must be
  avoided
• Contraindicated in patients with myocardial
  ischemia and ventricular arrhythmias or CCF.

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• Isometric exercise results in significant
  increase in
• Systemic vascular resistance
• Arterial pressure
• Heart rate
• CO
• LV filling pressure
• Heart size

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• 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

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• Increase LV volume
• Systolic murmur of HOCM decreased
• Click and murmur of MVP delayed

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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.

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• 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

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• PHASE1
• Intrathoracic pressure rises
• Transient increase in LV output and SBP

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• 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

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• A2-P2 interval narrows
• Attenuation of
• S3 and S4
• AS PS
• MR TR
• AR PR
• TS MS
• The volume of the carotid pulse also decreases.

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• Since LV volume is reduced
• Murmur of HOCM increased(65 sensitivity, 95
  specificity)
• Systolic click and murmur of MVP commence earlier

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• PHASE III - VALSALVA RELEASE
• During first two cycles following release,
  murmurs and sounds(S3 and S4) right side of heart
  return to normal
• After six to eight cycles sounds and murmurs
  originating from left side of heart returns to
  normal
• A2-P2 split increases
• Decrease SBP

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• PHASE IV OVERSHOOT PHASE
• Murmurs and heart sounds transiently augmented

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POSTPREMATURE VENTRICULAR CONTRACTIONS

• Changes in the intensity and character of the
  murmur during the postextrasystolic (postectopic)
  beat can provide clues to the diagnosis of
  valvular heart disease.
• Increase in ventricular filling ? increased
  ventricular volume
• Augmentation of cardiac contractility- post extra
  systolic potentiation
• In most circumstances, the effect of increased
  contractility supersedes the effect of an
  increased ventricular volume.

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• During postpremature beat augmented are
• ESM of AS and PS ?volume
• ?contractility
• HOCM ?contractility ? increase dynamic LVOT
  
• obstruction.
• ?volume ?decrease LVOT
  obstruction.
• Net effect increase gradient ?
  ? murmur.

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• Intensity of the ejection systolic murmur
  increases both in aortic stenosis and
  hypertrophic cardiomyopathy.
• Carotid pulse volume increases in AS and
  decreases or remains unchanged in HOCM ?
  Brockenbrough-Braunwald sign (postextrasystolic
  potentiation resulting in increased left
  ventricular outflow gradient and decreased or
  unchanged pulse pressure).

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• This characteristic pattern is known as the
  Brockenbrough-Braunwald sign.
• The decrease in pulse pressure after a premature
  ventricular contraction is due to reduced stroke
  volume caused by increased dynamic obstruction,
  which is due, in turn, to post-extrasystolic
  potentiation.

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• PSM of MR and of VSD - not altered (relatively
  little further increase in mitral valve flow or
  change in the LV-LA gradient)
• The murmur of aortic regurgitation also may
  increase due to an increased arterial pressure
  that augments the regurgitant flow.

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• Tricuspid regurgitation murmurs increase due to
  an increased right ventricular volume.
• In mitral valve prolapse, postextrasystolic
  potentiation causes a rapid rate of ejection and,
  therefore, an earlier onset of the click and the
  murmur.

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• 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

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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
• MDM accentuated

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MR

• Varies little with respiration
• Decrease murmur
• Sudden standing
• Valsalva
• Amyl Nitrate
• Augments the murmur
• Squatting
• Isometric Exercise

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AS

• Murmur increases on
• Post PVC beat
• squatting
• Reduces AS murmur
• Valsalva
• Standing
• handgrip

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AR

• EDM increases on
• sitting up and leaning forward
• Squatting
• Isometric exercise
• Vasopressors
• Decreases with
• Amyl Nitrate
• Valsalva

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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)

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HOCM

• Increase murmur in
• Valsalva
• Standing
• Post ectopic
• Decrease murmur in
• Sustained Handgrip
• squatting
• Methoxamine

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Dynamic auscultation helpful in

• AS X HOCM squatting
  (/v)
• 
  valsalva/standing (v/)
• AS x MR handgrip (v/)
• post pvc
  (/v)
• amyl nitrate
  (/v)

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• 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
  (-/)

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