Hypertrophic cardiomyopathy physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

There are numerous teachers on physical examination that allow one to distinguish hypertrophic cardiomyopathy from other conditions such as aortic stenosis.

Overview

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.

Neck

• "A wave" is prominent on JVP.
• Double carotid arterial pulse may be present.

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 AS by the fact that the murmur of AS 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% patients of HCM will also present with aortic regurgitation and in that case a diastolic decrescendo murmur may be present.
• If mitral regurgitation co exists with HCM then a holosystolic murmur will be beast heard at the caridac apex and left axilla.

Differentiating hypertrophic cardiomyopathy and valvular aortic stenosis

	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)