Normal Second heart sound (Identify the abnormalities of S2)

The most difficult thing in auscultation is to identify the abnormalities of S2.

Physiology of Second heartsound
Two components for 2nd heart sound are- aortic and pulmonary

Aortic component it is the 1st component and loud one heard in all areas.

Pulmonary component - 2nd component and soft, heard only over pulmonary area.

Normal second heart sound
It is a high pitched sound with normal split - 2 components are separately heard during inspiration and as single component during expiration over the pulmonary area.
Distance between the 2 components during inspiration is 0.04 sec, during expiration is 0.02 sec. Human ear can appreciate, when the distance between the 2 components is 0.03 or more. Normal second heart sound is expressed as - normal in intensity and normal split with respiration.

Things to look for in S2:
Intensity
Splitting
A2 heard over aortic area and pulmonary area and the apex.
P2 heard over pulmonary area and 2-4 LICS only and not at the apex.
P2 heard over the apex only in pulmonary artery hypertension and in young.
Best site for S2 in COPD - epigastrium.

Aortic regurgitation clinical presentation

What are the symptoms of aortic regurgitation
What are the clinical signs of aortic regurgitation
Describe the pulse in aortic regurgitation
What is water-hammer pulse ?
Describe the heart sounds in aortic regurgitation
Describe the murmurs in aortic regurgitation
What is the effect of other cardiac lesions in aortic regurgitation
Assessing severity of aortic regurgitation
Causes of Aortic regurgitation
Acute aortic regurgitation- Etiology,Features,difference of Acute and Chronic AR
Differentiate aortic regurgitation due to syphilis and rheumatic AR
Discuss the differential diagnosis of AR (Aortic regurgitation)
What are the investigation finding in aortic regurgitation
How will you manage a case of aortic regurgitation
Surgical management of patients with AR (Aortic regurgitation)

What is water-hammer pulse ?

Bounding pulse is commonly seen in hyperkinetic circulatory states, here the pulse volume is high due to highpulse pressure with increased blood flow.

What is water-hammer pulse (or high volume collapsing pulse)?

This pulse is characterised by :

• High pulse volume 
• Sharp rise.
• Ill-sustained
• Sharp fall.

High volume pulse gives the water-hammer character when the pulse pressure is at least more than  60 mm of Hg. A collapsing pulse usually occurs when there is rapid run-off of blood from the aorta or the arterial system. Carotid artery is used for detecting collapsing nature of pulse

The striking features of collapsing pulse are: 

• Abrupt upstroke, ill sustained peak and  abrupt downstroke and collapsing feel under the palpating hand
• Thrust produced by the abrupt upstroke of the collapsing  pulse will resemble the thrust produced by the tilting of the water hammer toy and the abrupt downstroke of the pulse produces collapsing feel.

How will you demonstrate the water-hammer pulse ?

• First you should palpate the wrist in such a way that your webs fall on the radial artery and rest of the palm lies over the ulnar artery of the patient Now you should e xamine the volume of the pulse for few seconds. 
• Elevate the whole upper limb suddenly above the  patients shoulder ( you may give a support in the elbow to prevent its flexion) mean while trv to recognise any changes in the volume of the pulse. In water-hammer pulse, the  pulse volume increases from the basal level (i.e. volume at the beginning of the examination) after elevation of patients upper limb.
• For examination of the pulse in this manner  one should stand within the ‘angle’ formed between the patients body and the said upper extremity. The right sided pulse should be examined by the right hand with the examiner standing on the right side of patient , and vice-versa for the left. You can observe the increase in pulse volume sharp rise and the sharp fall.

Why the name water-hammer pulse is given?

This pulse is so termed after a toy called water-hammer’. This is a peculiar toy with a glass cylinder that is half filled with water and half with vacuum (two ends being closed). If the toy is suddenly placed upside down, the column of water will strike the other end of the cylinder with a blowing sound. This is why this pulse is termed  waterhammer pulse where the pulse strikes the fingers like the thud of a hammer.

What is most important the cause of water-hammer pulse?

It is aortic regurgitation

Why this type of pulse is seen in Aortic regurgitation?

Waterhammer pulse is seen in AR due to the following reasons

High systolic pressure occur due to

• In AR, as the left ventricular stroke volume is high systolic pressure is also high and it is responsible for sharp rise' in the pulse.

The collapsing nature is due to low diastolic pressure which is seen due to 

• Diastolic leak back into the left ventricle from aorta.
• There is rapid run-off to the periphery as a result of decreased systemic vascular resistance, the barorcceptors in the aortic arch is stimulated by increased cardiac output and result is reflex vasodilatation of the peripheral vessels into which the blood flows rapidly.

Why do you elevate the arm for eliciting the collapsing pulse?

• Due to the effect of gravity, there is fall of blood column with resulting in vasodilatation and thus, it helps to reduce the diastolic pressure more. Hence  the pulse pressure widens,
• It may be so that while we elevate the limb the artery palpated becomes more in line with that of aorta after elevation of the arm.So it allows direct systolic ejection and diastolic backward flow resulting in collapsing pulse.

What are the other parts to be examined in water hammer pulse?

• You should count the rate (bradycardia in complete heart block: tachycardia in thyrotoxicosis).
• See the condition of the vessel wall (for atherosclerosis).
• See the facies for exophthalmos or examine for tremor to rule out thyrotoxicosis).
• You should record the surface temperature (pyrexia).
• Examine for anaemia (severe anaemia).
• Examine for jaundice to rule out cirrhosis with hepato-cellular failure.
• Examine the chest for emphysema (chronic cor pulmonale).
• Always auscultate the aortic and neoaortic area for an earlv diastolic murmur of AR.
• Search for peripheral signs of AR such as , for capillary pulsation, digital pulsation, carotid dance, pistol shot sound which are associated features of water-hammer pulse.

Describe the pulse in aortic regurgitation

The pulse in aortic regurgitation is called as Corrigans pulse or collapsing pulse.

1.    It has rapid upstroke.

2.    Rapid down stroke.

3.    ill sustained peak.

it is due to the

1.    Early diastolic reflux of blood into the left ventricle.

2.    There is low systemic vascular resistance.

Bisferien’s pulse may be seen in

1.    Moderate to severe AR.

2.    Moderate AR with mild AS.

What are the factors that affect pulse in AR

 Following factors may affect the pulse volume in AR.

They are

1.    Hypertension.

2.    Hypovolemia.

3.    Left ventricular dysfunction.

4.    Age of the patient.

5.    Associated aortic stenosis .

What are the factors that decrease the pulse volume

1.    Hypovolemia.

2.    Pulmonary artery hypertension.

3.    Left ventricular dysfunction.

4.    Associated valvular lesion – aortic stenosis.

What are the factors which increases the pulse volume in AR

1.    Hypertension.

2.    Elderly people.

3.    Young people

Read related topics  -  

11:29 AM

Differentiate aortic regurgitation due to syphilis and rheumatic AR

How will you differentiate between aortic regurgitation due to syphilis and rheumatic fever?

The pathology of AR in syphilis and rheumatic fever are different. In syphilis there is aortic root dilatation and in rheumatic fever there is valve damage.

Features of Rheumatic AR

1.    Usually affect young individuals

2.    Past history of rheumatic fever may be present

3.    Other valves may be affected

4.    Usually there is no diastolic thrill

5.    A₂ diminished 

6.    Murmur is of blowing character

7.    It is best heard on 3^rd left intercostals space

8.    Peripheral signs of AR are present.

Features of syphilitic AR

1.    Older individuals are affected

2.    History of exposure to syphilis present

3.    Syphilitic AR is usually an isolated lesion

4.    Diastolic thrill is more common than rheumatic AR

5.    A_2­ is usually loud tambour like

6.    Murmur is ringing, cooing, or musical in nature

7.    Best heard along the right sternal border.

8.    Peripheral sign are more marked than rheumatic AR.

Acute aortic regurgitation- Etiology,Features,difference of Acute and Chronic AR

Acute aortic regurgitation occur rapidly. Clinical features are different from chronic aortic regurgitation.

          In this session we will learn about

1.    Etiology of acute AR

2.    Clinical signs of acute AR

3.    Difference between acute AR and chronic AR

Acute AR etiology

1.    Dissection of aorta

2.    Infective endocarditis

3.    Trauma

Features of acute AR

1.    Pulse rate à Tachycardia

2.    Increased chance for hypotension

3.    There won’t be cardiomegaly

4.    Increased chance for pulmonary artery hypotension

-          Left parasternal heave

-          Loud P2 will be present

Following  changes are noted in heart sound

- S₁ is soft

- S₂ is single and P₂ is loud.

- LVS₃, S₄ are common.

          S₁ is soft because of the elevated left ventricular end diastolic pressure closing the valve prematurely.

Murmur in acute AR

          Soft EDM (early diastolic murmur) is heard in acute AR.

It is due to low cardiac output.There is decreased pressure gradient between aorta and left ventricle due to elevated LVEDP.

In acute AR, tachycardia will decrease the duration of diastole  and obscure the murmur of AR.

Austin flint murmur is produced due to premature valve closure due to elevated LVEDP.

Absent peripheral signs in acute AR is due to peripheral vasoconstriction, which attenuate the peripheral signs.

How will you differentiate between acute and chronic AR.

	Acute AR	Chronic AR
Pulse	Pulses parvus	Collapsing pulse
Blood pressure	Hypotension	Normal BP
Apex	No cardiomegaly	Cardiomegaly present
Pulmonary hypertension	Common	Uncommon
LVS4	Common	Rare
EDM(Early Diastolic Murmur)	Short EDM	Long EDM

Severity of AR – Assessed with hills sign

Discuss the differential diagnosis of AR (Aortic regurgitation)

Most important differential diagnosis of AR murmur are mitral stenosis and pulmonary regurgitation. Careful clinical examination of patients pulse, auscultation of cardiac murmur and dynamic auscultation will help to differentiate between them.

          The following charts will give you the major difference between aortic regurgitation and pulmonary regurgitation.

	Aortic regurgitation	Pulmonary regurgitation
Pulse	Collapsing pulse	Normal
Apex	Forceful	Normal
Features of PAH (Pulmonary artery hypertension)	Absent	Present
Murmur	Early diastolic murmur in 2nd aortic area that is conducted downward	EDM confined to pulmonary area

 Difference between AR with austinflint and mitral stenosis murmur

	AR with Austin flint murmur	Mitral stenosis
Pulse	Collapsing pulse	Low volume pulse
Atrial fibrillation	Less common	More common
Apex	Forceful apex with cardiomegaly	Tapping apex – no cardiomegaly
PAH	Uncommon	Common
S1 (First head sound)	Soft	Loud
Opening snap	Absent	Present