Page 32 - Medicine and Surgery

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28 Chapter 2: Cardiovascular system

of the right atrium. This may occur in right-sided heart Timing to systole or diastole is achieved by palpation
failure, congestive cardiac failure and pulmonary em- of the carotid pulse whilst auscultating. A systolic mur-
bolism. muroccursatthesametimeasthecarotidpulse,whereas
a diastolic murmur occurs in the pause between carotid
pulses. Murmurs are further described according to their
Precordial heaves, thrills and pulsation
relationship to the cardiac cycle.
A parasternal heave is a cardiac impulse palpated by Asystolic murmur may be pansystolic when the first

placing the flat of the hand on the costal cartilages, to and second heart sounds cannot be heard separate
the left of the patient’s sternum. It may be due to right fromthemurmur.Thisoccursinmitralregurgitation,
ventricular hypertrophy when the impulse is at the tricuspid regurgitation and with a ventricular septal
same time as the apex beat and carotid pulsation. Less defect.
commonly it is due to left atrial enlargement when An ejection systolic murmur is a crescendo–decres-
the pulsation occurs before the apex beat or carotid cendo murmur and the second heart sound can be
pulsation. heard distinct from the end of the murmur. It is heard
A thrill is a palpable murmur and is due to turbulent with aortic stenosis, pulmonary stenosis and with an

blood flow. A thrill is indicative of a loud murmur. atrial septal defect (the sound being produced by in-
The flat of the hand should be placed at the base and creased flow across the pulmonary valve).
apex of the heart. For example, a diastolic thrill at A late systolic murmur is heard in mitral valve pro-
the apex is suggestive of severe mitral stenosis (aortic lapse.
regurgitation rarely produces a thrill). An early diastolic murmur is heard with aortic re-
Theapexbeatisdefinedasthemostinferiorandlateral gurgitation, and a mid-late diastolic murmur is heard

cardiac pulsation. It should be identified and its po- with mitral stenosis.
sition defined according the intercostal space (count The area in which the murmur is heard at the greatest
down from the sternal angle which is at the second in- intensity and any radiation should be noted. This is most
tercostal space) and the relationship to the chest (mid- helpful when the flow of blood is considered according
clavicular line, anterior axillary line, etc). The normal to the lesion, for example aortic stenosis radiates to the
position is the fourth or fifth intercostal space in the neck, mitral regurgitation radiates to the axilla. The in-
left midclavicular line. The character of the pulsation tensity of the murmur may be graded (see Table 2.2) and
should also be palpated, but these may be subtle (see the pitch also noted.
Table 2.1).
Investigations and procedures
Heart murmurs
Coronary angioplasty
Heart murmurs are the result of turbulent blood flow.
Certain features of any murmur should be noted. Coronary angioplasty is a technique used to dilate
stenosed coronary arteries in patients with ischaemic
heart disease. The indications for use of angioplasty have
Table 2.1 Character of an abnormal apex beat changed over the years with the technique now used for
Typical underlying
Description Character lesion Table 2.2 Simple grading of the intensity of a
Tapping Sudden but brief Mitral stenosis heart murmur
pulsation
Thrusting Vigorous, Mitral or aortic Grade Description
nonsustained regurgitation 1/4 Just audible with concentration
Heaving Vigorous and Aortic stenosis, 2/4 Easily audible, but not loud
sustained systemic 3/4 Loud
hypertension 4/4 Loud and audible over a wide area