Hypertrophic cardiomyopathy physical examination: Difference between revisions
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{{Hypertrophic cardiomyopathy}} | {{Hypertrophic cardiomyopathy}} | ||
{{CMG}} | {{CMG}} {{AE}} {{Soroush}} | ||
==Overview== | ==Overview== | ||
There are numerous | There are numerous findings on [[physical examination]] that allow one to distinguish hypertrophic cardiomyopathy from other conditions such as [[aortic stenosis]]. On [[physical examination]], (as shown in the table below) maneuvers that decrease [[left ventricular]] filling augment the [[murmur]] and maneuvers that increase [[afterload]] or filling decrease the [[Murmurs|murmur]]. | ||
== | ==Physical Examination== | ||
* The physical findings of HCM are associated with the dynamic outflow obstruction that is often present with this disease.<ref name=":0">Maron BJ. Hypertrophic cardiomyopathy. Lancet 1997;350:127–33.</ref><ref name=":1">Maron BJ. Hypertrophic cardiomyopathy. A systematic review. JAMA 2002;287:1308–20.</ref><ref name=":2">Maki S, Ikeda H, Muro A et al. Predictors of sudden cardiac death in | |||
hypertrophic cardiomyopathy. Am J Cardiol 1998;82:774–8.</ref><ref name=":3">Maron BJ, Casey SA, Poliac LC, Gohman TE, Almquist AK, Aeppli DM. Clinical course of hypertrophic cardiomyopathy in a regional United | |||
States cohort. JAMA 1999;281:650–5.</ref><ref name=":4">Maron BJ, Olivotto I, Bellone P et al. Clinical profile of stroke in 900 patients with hypertrophic cardiomyopathy. J Am Coll Cardiol 2002;39:301–7.</ref> <ref name=":5">Maron BJ. Hypertrophic cardiomyopathy. A systematic review. JAMA 2002;287:1308–20.</ref><ref name=":6">Maron BJ, Casey SA, Poliac LC, Gohman TE, Almquist AK, Aeppli DM. Clinical course of hypertrophic cardiomyopathy in a regional United States cohort. JAMA 1999;281:650–5.</ref><ref name=":7">Fay WP, Taliercio CP, Ilstrup DM, Tajik AJ, Gersh BJ. Natural history of hypertrophic cardiomyopathy in the elderly. J Am Coll Cardiol 1990;16:821–6.</ref><ref name=":8">Takagi E, Yamakado T, Nakano T. Prognosis of completely asymptomatic adult patients with hypertrophic cardiomyopathy. J Am Coll Cardiol 1999;33:206–11.</ref> | |||
===Appearance of the Patient=== | |||
*Patients with hypertrophic cardiomyopathy usually appear normal. | |||
===Vital Signs=== | |||
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse | |||
*Patients with hypertrophic cardiomyopathy are prone to [[Cardiac arrhythmia|arrhythmia]] | |||
===Skin=== | |||
*[[Skin]] examination of patients with hypertrophic cardiomyopathy is usually normal. | |||
== | ===HEENT=== | ||
* | * HEENT examination of patients with hypertrophic cardiomyopathy is usually normal. | ||
===Neck=== | ===Neck=== | ||
* "[[A wave]]" is prominent on [[JVP]]. | |||
* Double carotid arterial pulse may be present. | *[[Jugular venous distension]] | ||
** "[[A wave]]" is prominent on [[JVP]]. | |||
**When [[Congestive heart failure|CHF]] develops [[Jugular venous pressure|JVP]] is more prominent and [[Hepatojugular reflux]] might be present. | |||
*[[Carotid bruits|Carotid]] | |||
*Double [[Carotid|carotid arterial]] pulse may be present. | |||
===Lungs=== | |||
*[[Pulmonary]] examination of patients with hypertrophic cardiomyopathy is usually normal. | |||
===Heart=== | ===Heart=== | ||
* If dynamic outflow obstruction exists, physical examination findings that can be elicited include the pulsus bisferiens and the double apical impulse with each ventricular contraction. These findings, when present, can help differentiate HCM from [[aortic stenosis]]. | * If dynamic outflow obstruction exists, [[physical examination]] findings that can be elicited include the [[pulsus bisferiens]] and the double apical impulse with each [[Ventricular|ventricular contraction]]. These findings, when present, can help differentiate HCM from [[aortic stenosis]]. | ||
* In addition, if the individual has [[premature ventricular contraction]]s (PVCs), the change in the carotid pulse intensity in the beat after the PVC can help differentiate HCM from aortic stenosis. | * In addition, if the individual has [[premature ventricular contraction]]s (PVCs), the change in the carotid pulse intensity in the beat after the PVC can help differentiate HCM from [[aortic stenosis]]. | ||
* In individuals with HCM, the pulse pressure will decrease in the beat after the PVC, while in aortic stenosis, the pulse pressure will increase. | * In individuals with HCM, the pulse pressure will decrease in the beat after the PVC, while in aortic stenosis, the [[pulse pressure]] will increase. | ||
====Palpation==== | ====Palpation==== | ||
| Line 27: | Line 48: | ||
=====Heart Sounds===== | =====Heart Sounds===== | ||
* [[S1]] is normal. | * [[S1]] is normal. | ||
* There may be paradoxically split S2 in severe cases | * There may be paradoxically split [[Heart sounds|S2]] in severe cases | ||
* S3 gallop or S4 may also be present. | *[[S3 gallop]] or [[S4]] may also be present. | ||
* S2 is louder in HCM than | *[[S2]] is louder in HCM than [[aortic stenosis]]. | ||
=====Murmurs===== | =====Murmurs===== | ||
* The murmur is characteristically a crescendo-decrescendo [[systolic murmur]]. | * The murmur is characteristically a crescendo-decrescendo [[systolic murmur]]. | ||
* Best heard between the apex and left sternal border. | * Best heard between the apex and left [[sternal]] border. | ||
* It radiates to the suprasternal notch but not to the carotid arteries or neck thus differentiating it from aortic stenosis. | * It radiates to the [[suprasternal notch]] but not to the [[carotid arteries]] or neck thus differentiating it from [[aortic stenosis]]. | ||
* The cardiac [[heart murmur|murmur]] of HCM will sound similar to the murmur of [[aortic stenosis]]. However, this murmur will: | * The cardiac [[heart murmur|murmur]] of HCM will sound similar to the [[Heart murmur|murmur]] of [[aortic stenosis]]. However, this murmur will: | ||
:* increase in intensity with any maneuver that decreases the volume of blood in the left ventricle (such as standing, [[ | |||
:* increase in intensity with any maneuver that decreases the volume of blood in the left ventricle (such as standing, [[valsalva maneuver]], amyl nitrate, [[diuretic]] administration or [[Vasodilators|vasodilator]] administration). | |||
:* decrease in intensity with any maneuver that increases the volume of blood in the left ventricle (such as Mueller maneuver, squatting or handgrip). | :* decrease in intensity with any maneuver that increases the volume of blood in the left ventricle (such as Mueller maneuver, squatting or handgrip). | ||
* [[Hypertrophic cardiomyopathy]](HCM) can be differentiated from | * [[Hypertrophic cardiomyopathy]](HCM) can be differentiated from aortic stenosis by the fact that the murmur of [[aortic stenosis]] does not change substantially with maneuvers. | ||
* The character of the pulse in | * The character of the pulse in [[aortic stenosis]] is [[Pulsus parvus et tardus|parvus et tardus]], while a [[Pulsus bisferiens|bisferiens]] pulse is noted in HCM. | ||
* Associated murmurs: | * Associated murmurs: | ||
:* 10% patients | |||
:* If mitral regurgitation | :* 10% of the patients with HCM will also present with [[aortic regurgitation]] and in that case, a [[Diastolic murmurs|diastolic]] decrescendo murmur may be present. | ||
:* If [[mitral regurgitation]] coexists with HCM then a [[holosystolic murmur]] will be beast heard at the caridac apex and left [[axilla]]. | |||
{| border="1" style="background:LightSkyBlue" | {| border="1" style="background:LightSkyBlue" | ||
| Line 78: | Line 100: | ||
| Brisk, jerky, or bisferiens pulse (a collapse of the pulse followed by a secondary rise) | | Brisk, jerky, or bisferiens pulse (a collapse of the pulse followed by a secondary rise) | ||
|} | |} | ||
<br /> | |||
===Abdomen=== | |||
*[[Abdominal]] examination of patients with hypertrophic cardiomyopathy is usually normal. | |||
===Back=== | |||
* Back examination of patients with hypertrophic cardiomyopathy is usually normal. | |||
===Genitourinary=== | |||
*[[Genitourinary system|Genitourinary]] examination of patients with hypertrophic cardiomyopathy is usually normal. | |||
===Neuromuscular=== | |||
*[[Neuromuscular]] examination of patients with hypertrophic cardiomyopathy is usually normal. | |||
===Extremities=== | |||
* Extremities examination of patients with hypertrophic cardiomyopathy is usually normal. | |||
* If they develop [[Congestive heart failure|heart failure]] the followings might be observed: | |||
*[[Clubbing]] | |||
*[[Cyanosis]] | |||
*Pitting/non-pitting [[edema]] of the upper/lower extremities | |||
==References== | ==References== | ||
Latest revision as of 17:54, 5 February 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2]
Overview
There are numerous findings on physical examination that allow one to distinguish hypertrophic cardiomyopathy from other conditions such as aortic stenosis. On physical examination, (as shown in the table below) maneuvers that decrease left ventricular filling augment the murmur and maneuvers that increase afterload or filling decrease the murmur.
Physical Examination
- The physical findings of HCM are associated with the dynamic outflow obstruction that is often present with this disease.[1][2][3][4][5] [6][7][8][9]
Appearance of the Patient
- Patients with hypertrophic cardiomyopathy usually appear normal.
Vital Signs
- Tachycardia with regular pulse or (ir)regularly irregular pulse
- Patients with hypertrophic cardiomyopathy are prone to arrhythmia
Skin
- Skin examination of patients with hypertrophic cardiomyopathy is usually normal.
HEENT
- HEENT examination of patients with hypertrophic cardiomyopathy is usually normal.
Neck
- Jugular venous distension
- "A wave" is prominent on JVP.
- When CHF develops JVP is more prominent and Hepatojugular reflux might be present.
- Carotid
- Double carotid arterial pulse may be present.
Lungs
- Pulmonary examination of patients with hypertrophic cardiomyopathy is usually normal.
Heart
- If dynamic outflow obstruction exists, physical examination findings that can be elicited include the pulsus bisferiens and the double apical impulse with each ventricular contraction. These findings, when present, can help differentiate HCM from aortic stenosis.
- In addition, if the individual has premature ventricular contractions (PVCs), the change in the carotid pulse intensity in the beat after the PVC can help differentiate HCM from aortic stenosis.
- In individuals with HCM, the pulse pressure will decrease in the beat after the PVC, while in aortic stenosis, the pulse pressure will increase.
Palpation
- Powerful apical precordial impulse is present which may be shifted laterally.
Auscultation
Heart Sounds
- S1 is normal.
- There may be paradoxically split S2 in severe cases
- S3 gallop or S4 may also be present.
- S2 is louder in HCM than aortic stenosis.
Murmurs
- The murmur is characteristically a crescendo-decrescendo systolic murmur.
- Best heard between the apex and left sternal border.
- It radiates to the suprasternal notch but not to the carotid arteries or neck thus differentiating it from aortic stenosis.
- The cardiac murmur of HCM will sound similar to the murmur of aortic stenosis. However, this murmur will:
- increase in intensity with any maneuver that decreases the volume of blood in the left ventricle (such as standing, valsalva maneuver, amyl nitrate, diuretic administration or vasodilator administration).
- decrease in intensity with any maneuver that increases the volume of blood in the left ventricle (such as Mueller maneuver, squatting or handgrip).
- Hypertrophic cardiomyopathy(HCM) can be differentiated from aortic stenosis by the fact that the murmur of aortic stenosis does not change substantially with maneuvers.
- The character of the pulse in aortic stenosis is parvus et tardus, while a bisferiens pulse is noted in HCM.
- Associated murmurs:
- 10% of the patients with HCM will also present with aortic regurgitation and in that case, a diastolic decrescendo murmur may be present.
- If mitral regurgitation coexists with HCM then a holosystolic murmur will be beast heard at the caridac apex and left axilla.
| Aortic stenosis | Hypertrophic cardiomyopathy | |
|---|---|---|
| Echocardiography | ||
| Aortic valve calcification | Common | No |
| Dilated ascending aorta | Common | Rare |
| Ventricular hypertrophy | Concentric LVH | Asymmetric, often involving the septum |
| Physical examination | ||
| Murmur of AI | Common | No |
| Pulse pressure after PVC | Increased | Decreased |
| Valsalva maneuver | Decreased intensity of murmur | Increased intensity of murmur |
| Carotid pulsation | Normal or tardus et parvus | Brisk, jerky, or bisferiens pulse (a collapse of the pulse followed by a secondary rise) |
Abdomen
- Abdominal examination of patients with hypertrophic cardiomyopathy is usually normal.
Back
- Back examination of patients with hypertrophic cardiomyopathy is usually normal.
Genitourinary
- Genitourinary examination of patients with hypertrophic cardiomyopathy is usually normal.
Neuromuscular
- Neuromuscular examination of patients with hypertrophic cardiomyopathy is usually normal.
Extremities
- Extremities examination of patients with hypertrophic cardiomyopathy is usually normal.
- If they develop heart failure the followings might be observed:
References
- ↑ Maron BJ. Hypertrophic cardiomyopathy. Lancet 1997;350:127–33.
- ↑ Maron BJ. Hypertrophic cardiomyopathy. A systematic review. JAMA 2002;287:1308–20.
- ↑ Maki S, Ikeda H, Muro A et al. Predictors of sudden cardiac death in hypertrophic cardiomyopathy. Am J Cardiol 1998;82:774–8.
- ↑ Maron BJ, Casey SA, Poliac LC, Gohman TE, Almquist AK, Aeppli DM. Clinical course of hypertrophic cardiomyopathy in a regional United States cohort. JAMA 1999;281:650–5.
- ↑ Maron BJ, Olivotto I, Bellone P et al. Clinical profile of stroke in 900 patients with hypertrophic cardiomyopathy. J Am Coll Cardiol 2002;39:301–7.
- ↑ Maron BJ. Hypertrophic cardiomyopathy. A systematic review. JAMA 2002;287:1308–20.
- ↑ Maron BJ, Casey SA, Poliac LC, Gohman TE, Almquist AK, Aeppli DM. Clinical course of hypertrophic cardiomyopathy in a regional United States cohort. JAMA 1999;281:650–5.
- ↑ Fay WP, Taliercio CP, Ilstrup DM, Tajik AJ, Gersh BJ. Natural history of hypertrophic cardiomyopathy in the elderly. J Am Coll Cardiol 1990;16:821–6.
- ↑ Takagi E, Yamakado T, Nakano T. Prognosis of completely asymptomatic adult patients with hypertrophic cardiomyopathy. J Am Coll Cardiol 1999;33:206–11.