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Talk. Mumble. Mutter. Grapevine. Sussuration. Scuttlebutt. Whisper. Murmur. Undertone. Buzz. Hearsay. Hum. Purr. Drone. Brool. Cry. Rumble. Gossip. Rumor. The Case. 62 yo M, pre-op eval for total L hip replacement in 8 weeks Healthy, no cardiac or pulmonary history

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The Case

  • 62 yo M, pre-op eval for total L hip replacement in 8 weeks
  • Healthy, no cardiac or pulmonary history
  • No prior cardiac workup
  • Able to swim and ice skate for hours without CP or SOB
  • EKG normal, labs normal
  • New II/VI mid systolic crescendo-decrescendo murmur with radiation to carotids

What do you want to do?

Oops, sorry – it was a hip fracture; he needs surgery tomorrow.

What do you want to do now?

heart sounds what s up with that apologies to brendan
Heart Sounds – What’s Up With That? (apologies to Brendan)
  • Sound is a form of energy resulting from oscillation of pressure levels.
  • S1 and S2 result from sudden deceleration of a mass of blood when valves close.
  • Snaps & Clicks are sounds made by the valves themselves.
  • Murmurs are the result of turbulent blood flow, typically across a valve.
can you identify murmurs
Can you identify murmurs?
  • On average, internal med residents identified only 20% of heart sounds accurately, a percentage not different from medical students or family practice residents.
  • Americans, Canadians, and Brits all stink about equally.
  • Accuracy improved in residents who play musical instruments or who study with audiotapes
can your attending
Can your attending?
  • Probably not. In patients referred by PCP for echo, about 50% of the time the echo didn’t match the pre-test Dx.
  • Cardiologists and senior cardiology fellows are the exception, and seem to have good diagnostic ability for most murmurs.
what do we do about it
What do we do about it?
  • Given the much better accuracy of diagnostic aids (echo, angiography, nuclear imaging, invasive hemodynamic monitoring), some authors think it’s a waste of resources for anyone besides cardiologists to learn about murmurs.
  • Everyone else says we need to educate residents better.
  • Aren’t you glad you’re here?
how to listen
How to listen
  • Pt in left lateral decubitus position
  • Stethoscope only touches skin
  • Quiet room
  • Tight seal with earpieces
  • S2 best heard upper sternum
  • S3 and S4 best heard with bell
  • Know your maneuvers
  • Decreases venous return and increases arterial resistance
  • First described in 1704 as a “method of cleaning pus from the middle ear”
  • Need to perform for 15-20 seconds
  • Confirm by tense abdominal muscles and & + JVD
  • Watch for inadvertent Valsalva with other maneuvers
abdominal pressure
Abdominal pressure
  • Increases venous return
  • Push inward and upward at R costal margin
  • Murmur should change over time
leg elevation
Leg elevation
  • Increase vascular return and also vascular resistance
  • Wait 20 seconds before expecting a change in murmur
postural change
Postural Change
  • Standing to squatting increases venous return and also vascular resistance
  • Squatting to standing decreases venous return and vascular resistance
  • Check immediately after change in posture
arterial occlusion
Arterial occlusion
  • Increases vascular resistance
  • Pump up pressure cuff on both arms to 20-40 mmHg above systolic BP
  • Wait 20 seconds before evaluating change in murmur
evaluating carotid rate of rise
Evaluating carotid rate of rise
  • “… a normal rate of rise feels like a sharp tap…”
  • “… an abnormal rate of rise feels like a nudge.”
  • “An abnormal rate of rise can also feel like a weak tap followed by a nudge or push.”
evaluating carotid volume
Evaluating carotid volume
  • “…normal carotid volume is easily felt with light palpation…”
  • “…a reduced carotid volume is difficult to feel even with firm palpation.”
pulse delays
Pulse delays
  • Can check for delay between right brachial artery and right radial artery
  • Can check for delay between apical impulse and right carotid pulse
  • Any palpable discrepancy between sites using either method is abnormal
innocent murmur
Innocent murmur
  • Short systolic ejection murmur
  • Loudest at left sternal border
  • Grade 1-2/6
  • Normal S2
  • No other exam abnormalities
  • No evidence LVH or dilatation
  • No thrill
  • No increase with Valsalva
how reliable is this
How reliable is this?
  • Early study showed 68% sensitivity compared with echo
  • Recent study showed 100% sensitivity (cardiologists and senior cardiology fellows) in military recruits
  • Study evaluated 72 patients referred for eval of systolic murmur; 30 with innocent and 19 with transient murmurs all had negative echoes. All 9 positive findings from 30 patients with abnormal exams.
sensitivity and specificity
Sensitivity and Specificity
  • Will report for murmurs when available; from study by Lembo (NEJM 1988)
  • 50 patients (all ages) with non-innocent murmurs evaluated by cardiologists
  • Separated from Pt’s by partition
  • Stethoscope fastened to Pt with elastic
  • Gold standard was angiography or unequivocal echo
cardiologist correlation
Cardiologist Correlation
  • Will report for murmurs when available; from study by Attenhofer (Amer J Med 2000)
  • 100 patients (mean age 58)
  • Cardiologist made Dx based solely on exam
  • Gold standard was echo only
mitral valve prolapse
Mitral valve prolapse
  • Systolic click makes diagnosis, with or without a murmur.
  • Clicks occur shortly after S1, get earlier as patient stands
  • Varies greatly between patients, not reliable even with same patient at different times (not sensitive)
  • Cardiologists were right in Dx this only 55% of the time (compared with echo)
hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy
  • Murmur should get quieter with passive leg raise: 85% sensitive and 91% specific
  • Murmur should (similarly) get quieter when patient goes from standing to squatting: 95% sensitive and 85% specific
  • Murmur should get louder when patient goes from squatting to standing position: 95% sensitive and 84% specific
  • Valsalva should make murmur louder: 65% sensitive and 96% specific
tricuspid regurgitation
Tricuspid regurgitation
  • Murmur getting louder with quiet inspiration is strongly suggestive of right sided-lesion (TR, PS); is diagnostic in deciding between TR and MR.
  • Abdominal pressure technique is reliable in increasing the murmur intensity of TR.
mitral regurgitation
Mitral regurgitation
  • Absence of a murmur in the mitral window (mid left thorax, fifth intercostal space) significantly reduces odds of MR.
  • Transient arterial occlusion very accurate for ruling in and ruling out MR or VSD: 78% sensitive and 100% specific
  • Handgrip increases murmur and is useful for distinguishing from AS, HCM, Right sided.
  • Non-cardiologists are much worse at this evaluation than cardiologists – cardiologists were right 88% of the time
aortic stenosis
Aortic stenosis
  • Significantly more likely if Pt has:
    • effort syncope
    • slow carotid rise
    • murmur peak in mid or late systole
    • decreased or absent S2
    • pulse delay
  • Significantly less likely if Pt has:
    • No murmur
    • No radiation to carotid
aortic stenosis25
Aortic stenosis
  • Many studies tried to come up with grading systems. Valid factors (to one degree or another) included:
    • Decreased carotid volume
    • Delayed carotid upstroke
    • Decreased or absent S2
    • Murmur loudest at RUSB
    • Valve calcification on CXR
  • Anesthesiologists also look for wide aorta on CXR from post-stenotic dilation
aortic stenosis26
Aortic stenosis
  • Munt (Amer Heart J 1999) looked at 123 asymptomatic subjects with AS, mean age 64, tried to figure out which findings were correlated with severe AS.
  • Murmur intensity p=0.003
  • Timing of peak intensity p=0.0002
  • Fading of S2 p=0.01
  • Carotid upstroke delay p<0.0001
  • Carotid upstroke amplitude blunting p<0.0001
  • Turns out that these were correlated with jet velocity, but not with critical AS as defined by death or need for valve replacement.
aortic stenosis27
Aortic stenosis
  • Nakamura (Am Heart J 1984) and Nitta (Chest 1987) both developed 16 point scales, with scores > 5 suggestive of critical AS; they used logistical regression to find relevance of 6 variables:
    • AV calcification on CXR [sens 43/63, spec 88/90]
    • LVH (EKG, echo, or both) [sens 53/49 spec 86/78]
    • Faint S2 [sens 24/52 spec 100/89]
    • or absent S2 [sens 18/16 spec 100/95]
    • Mid to Late murmur peak [sens 26/38 spec 96/98]
    • Carotid pulse Half-rise time [sens 31/38 spec 96/98]
    • Ejection Time index [sens 33/30 spec 100/100]
aortic stenosis28
Aortic stenosis
  • Nakamura (Am Heart J 1984) and Nitta (Chest 1987) overall results:
  • Nakamura model sens 59%, spec 95% for valve area < 0.75 cm2; gold standard was arteriography and hemodynamic monitoring. Excluded patients with cardiac dz.
  • Nitta model sens 95%, spec 96% for valve area <1.0 cm2. Also sens 95%, spec 72% for gradient > 40 mmHg.
  • Both studies gave the most points for peak, ET, and T-time. Same population as Nakamura.
  • Overall reliability of auscultation in asymptomatic subjects:
  • Sens 70% (CI 51-84%)
  • Spec 98% (CI 94-99%)
  • PPV 92%
  • NPV 92%
aortic stenosis echo
Aortic stenosis – Echo??
  • Das (QJ med 200) Echo for anyone with loud murmur, late systolic or holosystolic murmur, or exertional Sx. Innocent murmurs do not need echo.
  • Attenhofer (cardiologist correlation) Echo for systolic murmur of unknown cause.
  • Shry (military) Echo if abnormal exam, no echo if innocent or transient.
  • Richardson (Curr Prob Card 2000) Echo everyone or only echo if not innocent.
aortic stenosis guideline
Aortic stenosis - Guideline
  • ACC/AHA/ASE combined rec for whether to get echo based on exam:
  • Class I: cardio/respiratory Sx, or in asymptomatic patients with moderate probability of heart disease
  • Class IIb: asymptomatic, low probability card disease, but cannot rule out
  • Class III: asymptomatic, has characteristics of innocent murmur
what about pre op
What about pre-op?
  • Need to know for anesthesia:
  • Avoid brady- or tachycardia
  • Avoid changes in systemic vasc resistance
  • Optimize fluid volume to maintain venous return and filling
  • Maintain NSR
  • General anesthesia better than epidural
  • Pre-op ABX for surgery and dental work
what about pre op33
What about pre-op?
  • Stoelting (book): “Even in the presence of severe aortic stenosis, there is no evidence that elective non-cardiac surgery is associated with an increased risk.”
  • Kammerer (book): Goldman (1977), widely quoted 13% risk of cardiac death. “The only valve lesion associated with higher mortality” based on n=23. O’Keefe (1989) found 0% mortality with n=48.
what about pre op34
What about pre-op?
  • Raymer (Can J Anesth 1998): 55 patients mean age 73, mean valve area 0.92 cm2 did no differently than risk-matched controls (p=1.0)
  • Torsher (Am J Card 1998): 19 patients mean age 75, all with critical AS (<0.5 cm2). 2 patients died – one was high risk emergency (high mortality), second had MI (? related to AS). “AS patients…can undergo non-cardiac surgery with acceptable risk when appropriate intraoperative and postoperative management is used.”
what about pre op35
What about pre-op?

Mercado (Medical Consultation Pearls, Hanley & Belfus, 2002; 39-41): “Perioperative mortality is modest and suggests that lifesaving or other urgent surgery not be denied to patients with critical aortic stenosis.”

1) Aortic stenosis is a risk factor for postop cardiac complications

2) The magnitude of the risk varies according to different risk indices

3) Patients with severe or critical aortic stenosis can undergo surgery with an acceptable degree of risk if the indication for surgery is sufficiently compelling

  • Do a good exam
    • left lateral decub
    • touch skin, listen
    • quiet
    • good ear fit
    • correct stethoscope placement
    • use maneuvers
  • Play a musical instrument
  • Become a cardiologist
  • Look for:
    • effort syncope
    • angina
    • dyspnea
    • slow carotid rise
    • murmur peak in mid or late systole
    • decreased or absent S2
    • pulse delay
  • Maneuvers:
    • No change with inspiration (R side)
    • No change or quieter with Valsalva (HCM)
    • No change or quieter with squatting to standing (HCM)
    • No change or louder with passive leg raise (HCM)
    • No change or quieter with handgrip (MR or VSD)
    • No change or quieter with arterial occlusion (MR or VSD)
  • Trust the innocent murmur
    • Short systolic ejection murmur
    • Loudest at left sternal border
    • Grade 1-2/6
    • Normal S2
    • No other exam abnormalities
    • No evidence LVH or dilatation
    • No thrill
    • No increase with Valsalva
  • Most sensitive maneuvers were respiration and postural change
  • Most specific maneuver was Valsalva
  • Best predictors were S2, peak, T time, ET
  • Nitta has a nice model
  • If you have AS, have surgery anyway
  • Maintain optimal cardiac conditions intra- and postoperatively
  • Use prophylactic ABX