What are the causes of pulsation in different areas of precordium

Causes of prominent carotid pulsations are

1.        AR

2.        Hyperdynamic circulation such as anemia, thyrotoxicosis, fever

3.        Aortic aneurysm

4.        Atherosclerosis

5.        Exertion, emotions, excitement

6.        Kinked carotid artery

Causes of pulsations in suprasternal notch

1.        Hyperkinetic circulation

2.        AR

3.        Coarctation of aorta

4.        Aneurysm of arch of aorta

5.        Unfolding of arch of aorta

6.        High arch of aorta

Pulsations in pulmonary area is seen in 

1.        Children

2.        PAH (pulmonary artery hypertension)

3.        ASD (atrial septal defect)

4.        VSD (Ventricular septal defect)

5.        PDA (Patent ductus arteriosus)

6.        Idiopathic dilatation of pulmonary artery

Causes of left parasternal pulsation

1.     Right ventricular hypotrophy
2.      Left atrial hypertrophy

3.      Atrial septal defect

Causes of right parasternal pulsations

1.        Dextrocardia

2.        Dextroversion

3.        Aneurysm of ascending aorta

4.        Right atrial hypertrophy due to any cause.

Causes of epigastric pulsation

1.        Excitement in thin person

2.        RVH

3.        Aneurysm of abdominal aorta

4.        Transmitted hepatic pulsations in tricuspid incompetence

Pulsation at back

1.      Coarctation of aorta (Suzman’s sign)

2.       Pulmonary AV fistula

Juxta apical pulsation

1.     Ventricular aneurysm
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Causes of pulsations in different areas of precordium

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