Tricuspid regurgitation physical examination: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Tricuspid regurgitation}} | {{Tricuspid regurgitation}} | ||
{{CMG}} | {{CMG}} ; {AE}} {{VKG}} | ||
==Overview== | ==Overview== | ||
On examination, the [[jugular venous pressure]] is usually elevated, and 'cv' waves can be seen. The [[liver]] may be enlarged and is often pulsatile (the latter finding being virtually diagnostic of tricuspid insufficiency | On examination, the [[jugular venous pressure]] is usually elevated, and 'cv' waves can be seen. The [[liver]] may be enlarged and is often pulsatile (the latter finding being virtually diagnostic of [[tricuspid insufficiency]]. [[Peripheral edema]] is often found. In severe cases, there may be [[ascites]] and even [[cirrhosis]] (so-called '[[cardiac cirrhosis]]). [[Tricuspid insufficiency]] may lead to the presence of a pansystolic [[heart murmur]]. Such a [[murmur]] is usually of low frequency and it is best heard on the [[left sternal border]]. It tends to increase with [[inspiration]]. However, the [[murmur]] may be inaudible reflecting the relatively low pressures on the right side of the heart. A [[third heart sound]] may also be present. | ||
==Physical Examination== | ==Physical Examination== | ||
Clinical findings in patients presenting with tricuspid regurgitation is usually as a result of right sided [[heart failure]] and regurgitant blood flow across the [[tricuspid valve]] into the [[right atria]] during ventricular contraction. Patients with [[right-sided heart failure]] may present with [[peripheral edema]], [[cyanosis]], [[hepatosplenomegaly]], ascitis, [[cachexia]], and [[jaundice]]. Signs of [[left heart failure|left-sided heart failure]] will dominate in case of left ventricular dysfunction. | Clinical findings in patients presenting with [[tricuspid regurgitation]] is usually as a result of right sided [[heart failure]] and regurgitant blood flow across the [[tricuspid valve]] into the [[right atria]] during ventricular contraction. Patients with [[right-sided heart failure]] may present with [[peripheral edema]], [[cyanosis]], [[hepatosplenomegaly]], ascitis, [[cachexia]], and [[jaundice]]. Signs of [[left heart failure|left-sided heart failure]] will dominate in case of left ventricular dysfunction. | ||
===Neck=== | ===Neck=== | ||
* [[JVP]] is prominent and [[jugular venous distention]] is present. | * [[JVP]] is prominent and [[jugular venous distention]] is present. | ||
* "c-v" wave is prominent as a result of systolic regurgitation into the [[right atrium]] and it increases with [[inspiration]]. | * "c-v" wave is prominent as a result of systolic regurgitation into the [[right atrium]] and it increases with [[inspiration]]. | ||
* Severe regurgitation can also present as systolic thrill over the [[jugular vein]]. | * Severe [[regurgitation]] can also present as a [[systolic]] [[thrill]] over the [[jugular vein]]. | ||
*Don't confuse with carotid arterial pulse during the physical examination of the patient with jugular vein which is very pulsatile. | *Don't confuse with a [[Carotid arteries|carotid]] arterial pulse during the physical examination of the patient with [[jugular vein]] which is very pulsatile. | ||
{{#ev:youtube|VdgA3fcp7Cs}} | {{#ev:youtube|VdgA3fcp7Cs}} | ||
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===Heart=== | ===Heart=== | ||
====Palpation==== | ====Palpation==== | ||
* Dynamic right ventricular (RV) or lift may be present due to right ventricular enlargement. | * Dynamic [[Right ventricle|right ventricular]] (RV) or lift may be present due to [[right ventricular]] enlargement. | ||
* In the presence of [[pulmonary hypertension]], [[dilated pulmonary artery]] may result in pulsations felt over the left second intercostal space. | * In the presence of [[pulmonary hypertension]], [[dilated pulmonary artery]] may result in pulsations felt over the left second [[intercostal space]]. | ||
*In some patients when tricuspid regurgitation is severe pulsation can be noticed along the length of the right sternal border. | *In some patients when [[tricuspid regurgitation]] is severe pulsation can be noticed along the length of the right [[Sternum|sternal]] border. | ||
====Auscultation==== | ====Auscultation==== | ||
=====Heart Sounds===== | =====Heart Sounds===== | ||
* "[[S3 gallop]]" is present because of right ventricular dilation. | * "[[S3 gallop]]" is present because of right ventricular dilation. | ||
* Fourth heart sound ([[S4]]) may be present because of [[right ventricular hypertrophy]]. | *[[Fourth heart sound]] ([[S4]]) may be present because of [[right ventricular hypertrophy]]. | ||
* Pulmonic component of second heart sound ([[P2]]) is accentuated if [[pulmonary hypertension]] is present. | * Pulmonic component of second heart sound ([[P2]]) is accentuated if [[pulmonary hypertension]] is present. | ||
* Splitting of second heart sound ([[S2]]) may be notable if [[pulmonary hypertension]] is present. | * Splitting of second heart sound ([[S2]]) may be notable if [[pulmonary hypertension]] is present. | ||
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=====Murmurs===== | =====Murmurs===== | ||
* [[Holosystolic murmur|Holosystolic]] murmur is present. | * [[Holosystolic murmur|Holosystolic]] murmur is present. | ||
* Best heard at the right or left | * Best heard at the right or left mid sternal border or at the subxiphoid area. | ||
* In presence of right ventricular enlargement, murmur is even audible at the cardiac apex. | * In presence of right ventricular enlargement, the murmur is even audible at the cardiac apex. | ||
* | *In patients with tricuspid regurgitation diastolic rumble may be heard in some cases especially if there is a correlation with tricuspid stenosis. | ||
*A diastolic rumble may also be heard because of the increased blood flow across the [[tricuspid valve]] during [[diastole]] due to atrial septal defect. | |||
* A diastolic rumble may be | |||
'''Maneuvers''' | |||
*<nowiki/>Inspiration, leg raising, exercise, and hepatic compression increases the intensity of the [[Murmurs|murmur]] by increasing venous return to the heart. | |||
*Standing, [[amyl nitrate]] and [[valsalva maneuver]] decreases the murmur intensity by decreasing the venous return to the heart. | |||
* The intensity of the murmur varies with increase or decrease in pulmonary artery pressure if the patient is having pulmonary artery hypertension. | |||
*Rivero-Carvallo's sign can be observed in mild to moderate cases of tricuspid regurgitation.<ref name="pmid21400538">{{cite journal| author=Soto-Pérez-de-Celis E| title=José Manuel Rivero-Carvallo and the tricuspid valve. Enrique Soto-Pérez-de-Celis. | journal=Clin Cardiol | year= 2011 | volume= 34 | issue= 3 | pages= E9-11 | pmid=21400538 | doi=10.1002/clc.20755 | pmc=6652362 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21400538 }}</ref> | |||
{{#ev:youtube|Jk50shI9vV8}} | {{#ev:youtube|Jk50shI9vV8}} | ||
Latest revision as of 12:55, 28 April 2020
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Risk calculators and risk factors for Tricuspid regurgitation physical examination |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; {AE}} Vamsikrishna Gunnam M.B.B.S [2]
Overview
On examination, the jugular venous pressure is usually elevated, and 'cv' waves can be seen. The liver may be enlarged and is often pulsatile (the latter finding being virtually diagnostic of tricuspid insufficiency. Peripheral edema is often found. In severe cases, there may be ascites and even cirrhosis (so-called 'cardiac cirrhosis). Tricuspid insufficiency may lead to the presence of a pansystolic heart murmur. Such a murmur is usually of low frequency and it is best heard on the left sternal border. It tends to increase with inspiration. However, the murmur may be inaudible reflecting the relatively low pressures on the right side of the heart. A third heart sound may also be present.
Physical Examination
Clinical findings in patients presenting with tricuspid regurgitation is usually as a result of right sided heart failure and regurgitant blood flow across the tricuspid valve into the right atria during ventricular contraction. Patients with right-sided heart failure may present with peripheral edema, cyanosis, hepatosplenomegaly, ascitis, cachexia, and jaundice. Signs of left-sided heart failure will dominate in case of left ventricular dysfunction.
Neck
- JVP is prominent and jugular venous distention is present.
- "c-v" wave is prominent as a result of systolic regurgitation into the right atrium and it increases with inspiration.
- Severe regurgitation can also present as a systolic thrill over the jugular vein.
- Don't confuse with a carotid arterial pulse during the physical examination of the patient with jugular vein which is very pulsatile.
{{#ev:youtube|VdgA3fcp7Cs}}
Heart
Palpation
- Dynamic right ventricular (RV) or lift may be present due to right ventricular enlargement.
- In the presence of pulmonary hypertension, dilated pulmonary artery may result in pulsations felt over the left second intercostal space.
- In some patients when tricuspid regurgitation is severe pulsation can be noticed along the length of the right sternal border.
Auscultation
Heart Sounds
- "S3 gallop" is present because of right ventricular dilation.
- Fourth heart sound (S4) may be present because of right ventricular hypertrophy.
- Pulmonic component of second heart sound (P2) is accentuated if pulmonary hypertension is present.
- Splitting of second heart sound (S2) may be notable if pulmonary hypertension is present.
{{#ev:youtube|f2WYFIT_09Q}}
{{#ev:youtube|ntNNvRR1U38}}
Murmurs
- Holosystolic murmur is present.
- Best heard at the right or left mid sternal border or at the subxiphoid area.
- In presence of right ventricular enlargement, the murmur is even audible at the cardiac apex.
- In patients with tricuspid regurgitation diastolic rumble may be heard in some cases especially if there is a correlation with tricuspid stenosis.
- A diastolic rumble may also be heard because of the increased blood flow across the tricuspid valve during diastole due to atrial septal defect.
Maneuvers
- Inspiration, leg raising, exercise, and hepatic compression increases the intensity of the murmur by increasing venous return to the heart.
- Standing, amyl nitrate and valsalva maneuver decreases the murmur intensity by decreasing the venous return to the heart.
- The intensity of the murmur varies with increase or decrease in pulmonary artery pressure if the patient is having pulmonary artery hypertension.
- Rivero-Carvallo's sign can be observed in mild to moderate cases of tricuspid regurgitation.[1]
{{#ev:youtube|Jk50shI9vV8}}
Liver
- Hepatomegaly may be present.
- A thrill may be present due to the transmission of the systolic murmur to the liver.
Lungs
- Pulmonary rales might be present if left ventricular dysfunction is associated with the disease.
2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) [2]
Adolescents (DO NOT EDIT) [2]
| Class I |
| "1. Pulse oximetry at rest and/or during exercise is indicated for the initial evaluation of adolescent and young adult patients with TR if an atrial communication is present, and serially every 1 to 3 years, depending on severity. (Level of Evidence: C)" |
Sources
- 2008 ACC/AHA Guidelines incorporated into the 2006 guidelines for the management of patients with valvular heart disease [2]
References
- ↑ Soto-Pérez-de-Celis E (2011). "José Manuel Rivero-Carvallo and the tricuspid valve. Enrique Soto-Pérez-de-Celis". Clin Cardiol. 34 (3): E9–11. doi:10.1002/clc.20755. PMC 6652362 Check
|pmc=value (help). PMID 21400538. - ↑ 2.0 2.1 2.2 Bonow RO, Carabello BA, Chatterjee K; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Unknown parameter
|month=ignored (help)