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. 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]
Neck
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% 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.
| 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) |
Physical Examination
Physical examination of patients with [disease name] is usually normal.
OR
Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
OR
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
OR
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
Appearance of the Patient
- Patients with [disease name] usually appear [general appearance].
Vital Signs
- High-grade / low-grade fever
- Hypothermia / hyperthermia may be present
- Tachycardia with regular pulse or (ir)regularly irregular pulse
- Bradycardia with regular pulse or (ir)regularly irregular pulse
- Tachypnea / bradypnea
- Kussmal respirations may be present in _____ (advanced disease state)
- Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
- High/low blood pressure with normal pulse pressure / wide pulse pressure / narrow pulse pressure
Skin
- Skin examination of patients with [disease name] is usually normal.
OR
-
Description (Adapted from Dermatology Atlas)
-
Description (Adapted from Dermatology Atlas)
HEENT
- HEENT examination of patients with [disease name] is usually normal.
OR
- Abnormalities of the head/hair may include ___
- Evidence of trauma
- Icteric sclera
- Nystagmus
- Extra-ocular movements may be abnormal
- Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
- Ophthalmoscopic exam may be abnormal with findings of ___
- Hearing acuity may be reduced
- Weber test may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
- Rinne test may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
- Exudate from the ear canal
- Tenderness upon palpation of the ear pinnae/tragus (anterior to ear canal)
- Inflamed nares / congested nares
- Purulent exudate from the nares
- Facial tenderness
- Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae
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 [disease name] is usually normal.
OR
- Asymmetric chest expansion OR decreased chest expansion
- Lungs are hyporesonant OR hyperresonant
- Fine/coarse crackles upon auscultation of the lung bases/apices unilaterally/bilaterally
- Rhonchi
- Vesicular breath sounds OR distant breath sounds
- Expiratory wheezing OR inspiratory wheezing with normal OR delayed expiratory phase
- Wheezing may be present
- Egophony present/absent
- Bronchophony present/absent
- Normal/reduced tactile fremitus
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 co-exists with HCM then a holosystolic murmur will be beast heard at the cardiac apex and left axilla.
Abdomen
- Abdominal examination of patients with [disease name] is usually normal.
OR
- Abdominal distension
- Abdominal tenderness in the right/left upper/lower abdominal quadrant
- Rebound tenderness (positive Blumberg sign)
- A palpable abdominal mass in the right/left upper/lower abdominal quadrant
- Guarding may be present
- Hepatomegaly / splenomegaly / hepatosplenomegaly
- Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
Back
- Back examination of patients with [disease name] is usually normal.
OR
- Point tenderness over __ vertebrae (e.g. L3-L4)
- Sacral edema
- Costovertebral angle tenderness bilaterally/unilaterally
- Buffalo hump
Genitourinary
- Genitourinary examination of patients with [disease name] is usually normal.
OR
- A pelvic/adnexal mass may be palpated
- Inflamed mucosa
- Clear/(color), foul-smelling/odorless penile/vaginal discharge
Neuromuscular
- Neuromuscular examination of patients with [disease name] is usually normal.
OR
- Patient is usually oriented to persons, place, and time
- Altered mental status
- Glasgow coma scale is ___ / 15
- Clonus may be present
- Hyperreflexia / hyporeflexia / areflexia
- Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
- Muscle rigidity
- Proximal/distal muscle weakness unilaterally/bilaterally
- ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
- Unilateral/bilateral upper/lower extremity weakness
- Unilateral/bilateral sensory loss in the upper/lower extremity
- Positive straight leg raise test
- Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
- Positive/negative Trendelenburg sign
- Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
- Normal finger-to-nose test / Dysmetria
- Absent/present dysdiadochokinesia (palm tapping test)
Extremities
- Extremities examination of patients with [disease name] is usually normal.
OR
- Clubbing
- Cyanosis
- Pitting/non-pitting edema of the upper/lower extremities
- Muscle atrophy
- Fasciculations in the upper/lower extremity
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.