T HE A RTAND S CIENCEOF C ARDIAC P HYSICAL E XAMINATION

T

A

S

C

P

E

Management of Acute Pulmonary Embolism, edited by Stavros Konstantinides, MD, 2007 Stem Cells and Myocardial Regeneration,ed-

ited by Marc S. Penn, MD,PhD, 2007 Handbook of Complex Percutaneous Carotid

Intervention,edited by Jacqueline Saw,

MD, Jose Exaire, MD, David S. Lee, MD, Sanjay Yadav, MD, 2007

Preventive Cardiology: Insights Into the Preven- tion and Treatment of Cardiovascular Dis- ease, Second Edition,edited by JoAnne Micale Foody, MD, 2006

The Art and Science of Cardiac Physical Examination: With Heart Sounds and Pulse Wave Forms on CD,by Narasimhan Ranganathan,MD, Vahe Sivaciyan, MD, and Franklin B. Saksena, MD, 2006 Cardiovascular Biomarkers: Pathophysiology

and Disease Management,edited by David A.

Morrow,MD, 2006

Cardiovascular Disease in the Elderly,edited by Gary Gerstenblith, MD, 2005

Platelet Function: Assessment, Diagnosis, and Treatment,edited by Martin Quinn, MB BCh BAO,PhD, and Desmond Fitzgerald, MD,FRCPI,

FESC,APP, 2005

Diabetes and Cardiovascular Disease, Second Edition,edited by Michael T. Johnstone, MD,

CM,FRCP(C), and Aristidis Veves, MD,DSc, 2005 Angiogenesis and Direct Myocardial

Revascularization,edited by Roger J.

Laham,MD, and Donald S. Baim, MD, 2005 Interventional Cardiology: Percutaneous

Noncoronary Intervention, edited by Howard C. Herrmann, MD, 2005 Principles of Molecular Cardiology,

edited by Marschall S. Runge, MD, and Cam Patterson, MD, 2005

Heart Disease Diagnosis and Therapy: A Practical Approach, Second Edition, by M. Gabriel Khan,MD,FRCP(LONDON),FRCP(C),FACP,FACC, 2005

Cardiovascular Genomics: Gene Mining for Pharmacogenomics and Gene Therapy, edited by Mohan K. Raizada, ^PhD, Julian F. R. Paton, PhD, Michael J.

Katovich,PhD, and Sergey Kasparov, MD,

PhD, 2005

Surgical Management of Congestive Heart Failure, edited by James C. Fang, ^MD

and Gregory S. Couper, MD, 2005

Cardiopulmonary Resuscitation,edited by Joseph P. Ornato, MD,FACP,FACC,FACEP and Mary Ann Peberdy, MD,FACC, 2005

CT of the Heart: Principles and Applications, ed- ited by U. Joseph Schoepf, MD, 2005 Coronary Disease in Women: Evidence-Based

Diagnosis and Treatment, edited by Leslee J. Shaw, PhD and Rita F. Redberg, MD,FACC, 2004

Cardiac Transplantation: The Columbia University Medical Center/New York-Presbyterian Hospital Manual, edited by Niloo M.

Edwards,MD, Jonathan M. Chen, MD, and Pamela A. Mazzeo, 2004

Heart Disease and Erectile Dysfunction,edited by Robert A. Kloner, MD,PhD, 2004

Complementary and Alternative Cardiovascular Medicine,edited by Richard A. Stein, ^MD and Mehmet C. Oz, MD, 2004

Nuclear Cardiology, The Basics: How to Set Up and Maintain a Laboratory, by Frans J. Th.

Wackers,MD,PhD, Wendy Bruni, BS,CNMT, and Barry L. Zaret, MD, 2004

Minimally Invasive Cardiac Surgery, Second Edition,edited by Daniel J. Goldstein,

MD, and Mehmet C. Oz, MD 2004

Cardiovascular Health Care Economics, edited by William S. Weintraub, MD, 2003

Platelet Glycoprotein IIb/IIIa Inhibitors

in Cardiovascular Disease, Second Edition, edited by A. Michael Lincoff, MD, 2003 Heart Failure: A Clinician’s Guide to Ambulatory

Diagnosis and Treatment, edited by Mariell L.

Jessup,MD and Evan Loh, MD, 2003

C

P. C

,

A

M. A

,

C ONTEMPORARY C ^ARDIOLOGY

T ^HE A ^{RT AND} S ^CIENCE

OF C ^ARDIAC P ^HYSICAL E ^XAMINATION

With Heart Sounds and Pulse Wave Forms on CD

By

N ^ARASIMHAN R ^ANGANATHAN

MBBS

,

(

),

,

,

V ^AHE S ^IVACIYAN

MD

,

(

)

University of Toronto and St. Joseph's Health Centre, Toronto, Ontario, Canada

F ^RANKLIN B. S ^AKSENA

MD

,

,

,

(

),

Northwestern University School of Medicine, Chicago, IL

© 2006 Humana Press Inc.

999 Riverview Drive, Suite 208 Totowa, New Jersey 07512 www.humanapress.com

All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher.

The content and opinions expressed in this book are the sole work of the authors and editors, who have warranted due diligence in the creation and issuance of their work. The publisher, editors, and authors are not responsible for errors or omissions or for any consequences arising from the information or opinions presented in this book and make no warranty, express or implied, with respect to its contents.

Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the information published and to describe generally accepted practices. The contributors herein have carefully checked to ensure that the drug selections and dosages set forth in this text are accurate and in accord with the standards accepted at the time of publication. Notwithstanding, as new research, changes in government regulations, and knowledge from clinical experience relating to drug therapy and drug reactions constantly occurs, the reader is advised to check the product information provided by the manufacturer of each drug for any change in dosages or for additional warnings and contraindications. This is of utmost importance when the recommended drug herein is a new or infrequently used drug.

It is the responsibility of the treating physician to determine dosages and treatment strategies for individual patients.

Further it is the responsibility of the health care provider to ascertain the Food and Drug Administration status of each drug or device used in their clinical practice. The publisher, editors, and authors are not responsible for errors or omissions or for any consequences from the application of the information presented in this book and make no warranty, express or implied, with respect to the contents in this publication.

Cover design by Patricia F. Cleary

For additional copies, pricing for bulk purchases, and/or information about other Humana titles, contact Humana at the above address or at any of the following numbers: Tel.: 973-256-1699; Fax: 973-256-8341, E-mail:

orders@humanapr.com; or visit our Website: www.humanapress.com This publication is printed on acid-free paper. ∞

ANSI Z39.48-1984 (American National Standards Institute) Permanence of Paper for Printed Library Materials.

Photocopy Authorization Policy:

Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by Humana Press Inc., provided that the base fee of US $30.00 is paid directly to the Copyright Clearance Center at 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license from the CCC, a separate system of payment has been arranged and is acceptable to Humana Press Inc. The fee code for users of the Transactional Reporting Service is: [1-58829-776-4/06 $30.00].

Printed in the United States of America. 10 9 8 7 6 5 4 3 2 1 eISBN 1-59745-023-5

Library of Congress Cataloging-in-Publication Data Ranganathan, Narasimhan.

The art and science of cardiac physical examination : with heart sounds and pulse wave forms on CD / by Narasimhan Ranganathan, Vahe Sivaciyan, Franklin B. Saksena.

p. ; cm. -- (Contemporary cardiology) Includes bibliographical references and index.

ISBN 1-58829-776-4 (alk. paper)

1. Heart--Examination. 2. Heart--Diseases--Diagnosis. 3. Heart--Sounds. I. Sivaciyan, Vahe. II. Saksena, Franklin B. III. Title. IV. Series: Contemporary cardiology (Totowa, N.J. : Unnumbered)

[DNLM: 1. Heart Diseases--diagnosis. 2. Heart Function Tests--methods. 3. Heart Sounds--physiology. 4. Physical Examination--methods. WG 141 R196 2006]

RC683.R25 2006 616.1'2075--dc22

2006009499

To

Saroja Ranganathan, Ayda Sivaciyan,

and

Kathleen Saksena

Without their support,

this book would not have been possible.

P ^REFACE

vii

It has been our experience that instruction in physical examination of the heart in medical schools has been deteriorating since the advent of such modern diagnostic tools as two-dimensional echocardiography and nuclear imaging. At best, the teaching has been sketchy and too superficial for the student to appreciate the pathophysiological correlates. Both invasive and the noninvasive modern technologies have contributed substantially to our knowledge and understanding of cardiac physical signs and their pathophysiological correlates. However, both students and teachers alike appear to be mesmerized by technological advances to the neglect of the age-old art, as well as the substantial body of science, of cardiac physical examination. It is also sad to see reputed journals give low priority to articles related to the clinical examination.

Our experience is substantiated by a nationwide survey of internal medicine and cardiology training programs, which concluded that the teaching and practice of cardiac auscultation received low emphasis, and perhaps other bedside diagnostic skills as well (1). The state of the problem is well reflected in the concerns expressed in previous publications (2–4), including the 2001 editorial in the American Journal of Medicine (Vol. 110, pp. 233–235), entitled “Cardiac auscultation and teaching rounds: how can cardiac auscultation be resuscitated?”, as well as in the rebuttal, “Selections from current literature. Horton hears a Who but no murmurs—does it matter?” (5). The latter goes to the extent of suggesting that auscultation be performed only when cardiac symptoms are encountered in patients. This appears to be based on an exaggerated concern for the waste of time and resources. Implicit in this statement, if one chooses to agree with it, will be the acknowledgment of one’s failure as a physician—at least, a physician caring for patients.

On the contrary, we not only share the opinion of others that cardiac auscultation is a cost-effective diagnostic skill (6), we go one step further and suggest that all aspects of cardiac physical examination are very cost effective and rewarding in many ways. A properly obtained, detailed, and complete history of the patient’s problems and a thorough physical examination are never counterproductive to the interests of the patient.

Modern technological advances are here to stay. They should be an adjunct to the clinical examination of the patient, but they should not be allowed to replace the physical examination. Let’s not forget that many of these tools add to the rising costs of health care all over the world. A well-carried-out physical examination of the heart often provides the critical information necessary to choose the right investigative tool and to avoid the unnecessary ones. Even if one ignores the cost factor, a physician caring for a patient where advanced technologies may not be accessible (at nights and on weekends in some institutions, in rural or otherwise remote locations, during power failure and timesof natural or other disasters) should be able to assess and diagnose cardiac function and probable underlying pathology using the five senses, a stethoscope, and a sphygmo- manometer.

Mackenzie integrated the jugular venous pulse as part of the cardiovascular physical examination (7). Wood further went on to show that the precise analysis of the jugular

viii Preface venous pulse wave forms and the measurement of the venous pressure with reference to the sternal angle is possible at the bedside (8). Interpretation of the jugular venous pulse contour and the assessment of the pressure remains yet an occult art practiced only by experienced clinicians. Poor, ill-defined, and vague terms such as jugular venous distension are commonly used and written about even in reputed journals when cardiac physical findings are mentioned.

One of the satisfying features of medicine, aside from contributing to the clinical improvement of an ailing patient, is the intellectual excitement and satisfaction of arriving at the right conclusion through proper reasoning based on clues derived from the clinical examination of the patient. In addition, not surprisingly, some of the physical signs have also been shown, in this day and age of “evidence-based medicine,” to be of prognostic importance. For instance, elevated jugular venous pressure and the third heart sound in patients with symptomatic heart failure have been shown to have independent prognostic information (9). To understand the pathophysiological correlates of various cardiac signs and symptoms requires the same skills of logical thinking exhibited by any good clinician at work, and their development is one benefit of such a discipline. It is all the more important when the detection of an abnormal sound or sign can be related to other cardiac measurements (10). Improper understanding of the pathophysiological correlates would only result in testing the wrong hypotheses and possibly obtaining a misleading conclusion.

The purpose of The Art and Science of Cardiac Physical Examination is to arm the student of cardiology with the proper techniques and understanding of the art and science of the cardiac physical examination, to dispel myths and confusion, and to help develop skills required of any astute clinician.

This work is a culmination of long-standing experience in teaching and training physicians and physicians-to-be, as well as other students of cardiology. In fact, we have offered annually and continually refine a course of the same title at our institution in Toronto for more than 25 years. The course has always been well received and appreciated for both teaching methods and content. We utilize audiorecordings of heart sounds and murmurs, as well as videorecordings of jugular and precordial pulsations with simultaneously recorded sounds and flow signals for timing, all from actual patients collected over many years of clinical practice. Video display of the actual sounds and murmurs provides a real-time playback effect, and multiple listening devices with infrared transmission of sounds enhances the group teaching and learning experience. Refinements in the course have been stimulated by enthusiastic and inquisitive students and trainees and aided by our own research and studies, particularly with reference to the jugular venous flows and pulsations, as well as to precordial pulsations.

The organization of the material presented in this volume, The Art and Science of Cardiac Physical Examination, warrants some elaboration. We believe that the presentation helps integrate the science with concepts useful for logical application in clinical situations. The teaching method adopted is somewhat unique and, we believe, totally original in some sections. This is most evident in chapters on jugular venous pulse or precordial pulsations, as well as in the chapter on arterial pulse. Our approach to the interpretation of jugular venous pulsations highlights the proper method for integrating art with science at the bedside. We believe that it is different in many ways from other books describing cardiac examination. Every important topic has a summary of salient

and practical points directed toward clinical assessment. These serve as a quick review as well as pointing to concepts that need reinforcement.

Many illustrations of sounds and murmurs used in the text are derived from digital display of actual audiorecordings from patients. The pathophysiology of some of the important clinical cardiac conditions is shown in flow diagrams as well as in tabular format, permitting logical review and reinforcement. References at the end of each chapter were carefully chosen for their now classic approaches as well as for their diverse perspectives.

A special chapter covering local and systemic manifestations of cardiovascular disease, written by our colleague and friend Dr. Franklin B. Saksena, has been carefully illustrated and exhaustively documented from the literature.

The audio and the videorecordings of sounds and murmurs provided on the companion CD capture the jugular and the precordial pulsations from patients with the range of cardiac problems most likely to be encountered clinically. The CD is playable on any up- to-date computer, both Mac and PC. We intend that these videorecordings enhance learning both for an individual or a group of students and trainees in cardiology. They provide a real-time playback effect of heart sounds and murmurs displayed on an oscilloscope. Another unique feature in the videofiles is the presentation of simultaneous recordings of two-dimensional echocardiographic images with the audiorecordings of heart murmurs from a few patients with specific cardiac lesions.

Thus, we present The Art and Science of Cardiac Physical Examination with a firm conviction that it will be an invaluable asset in learning and teaching clinical cardiology.

Narasimhan Ranganathan,

MBBS,FRCP(C),FACP,FACC,FAHA

Vahe Sivaciyan, ^MD,FRCP(C)

References

1. Mangione S, Nieman LZ, Gracely E, Kaye D. The teaching and practice of cardiac auscultation during internal medicine and cardiology training. A nationwide survey. Ann Intern Med 1993;119:47–54.

2. Schneiderman H. Cardiac auscultation and teaching rounds: how can cardiac auscultation be resuscitated? Am J Med 2001;110:233–235.

3. Lok CE, Morgan CD, Ranganathan N. The accuracy and interobserver agreement in detecting the

‘gallop sounds’ by cardiac auscultation. Chest 1998;114:1283–1288.

4. Tavel ME. Cardiac auscultation. A glorious past—but does it have a future? Circulation 1996;93:1250–

1253.

5. Kopes-Kerr CP. Selections from current literature. Horton hears a Who but no murmurs—does it matter? Fam Pract 2002; 19:422–425.

6. Shaver, JA. Cardiac auscultation: a cost-effective diagnostic skill. Curr Probl Cardiol 1995; 7:441–

530.

7. Mackenzie J. The study of the pulse. London, Pentland, 1902.

8. Wood P. Diseases of the Heart and Circulation. Philadelphia, J.B. Lippincott, 1956.

9. Drazner MH, Rame JE, Stevenson LW, Dries DL. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. N Engl J Med 2001; 345:574–581.

10.. Marcus GM, Gerber IL, McKeown BH, et al. Association between phonocardiographic third and fourth heart sounds and objective measures of left ventricular function. JAMA 2005; 293:2238–2244.

Preface ix

A CKNOWLEDGMENT

I wish to express, on behalf of all the authors, our sincere thanks and gratitude to many individuals who have helped either directly or indirectly our efforts in the teaching of bedside clinical cardiology over the years and thereby made the publication of this work possible. First, our thanks go to all the patients who kindly volunteered their time for the purpose of medical education and teaching. I wish to express also my sincere thanks to all my colleagues in the cardiology division of St. Michael’s Hospital, University of Toronto, with whom I worked from 1970 to 1988, my colleagues at St. Joseph’s Health Centre since 1989, as well as the administration of the St. Joseph’s Health Centre for their support of our educational programs and endeavors. A special thanks is also due to Mr.

John Cooper and his family, whose kind donation toward the cardiology service at St.

Joseph’s Health Centre allowed the acquisition of a computer with a fast processor and modern video editing capabilities that eventually helped in the conversion of old technology to modern technology. We express our thanks also to Professor Emeritus Rashmi Desai of the Department of Physics at the University of Toronto and his colleague Dr. Katrin Rohlf of the Department of Chemistry, University of Toronto, for their input and comments.

We offer our profound gratitude and sincerest thanks most especially to Mr. Roger Harris, who is the head of the audiovisual department at St. Joseph’s Health Centre, without whose ingenuity and dedicated and continuing assistance, the publication of this book and its companion CD would not have been possible. Most of the audiorecordings were originally made on a four-channel Cambridge magnetic disc recorder of the 1960s.

In fact, we used to play these discs—even during our annual continuing medical education courses—using a storage oscilloscope and a television camera connected to large monitors for instant display of the waveforms. In 1989, after I joined St. Joseph’s Health Centre, I had the good fortune to begin my association with Roger Harris. With his assistance and advice, the audiorecordings were initially converted to videorecordings.

When reliable video editing programs with good and acceptable synchrony between the audio and the video tracks became available, Roger helped to digitize and archive these videorecordings. In addition, it is through his efforts we have made the successful transition to current technology, which enables display in the Windows media player on any up-to-date computer. Furthermore, his assistance has been invaluable for the production of all of the illustrations in the text as well as the production of the companion CD. Therefore, his enthusiasm for this project and many contributions are gratefully acknowledged and very much appreciated.

Finally, we express our sincere appreciation and thanks also to Mr. Balu Srinivasan for the professional assistance in the preparation of the CD.

Narasimhan Ranganathan,

MBBS,FRCP(C),^FACP,^FACC,^FAHA

x

C ^ONTENTS

xi

Preface ... vii

Acknowledgment ... x

Companion CD ... xv

Color Plates ... xvii

C

1 A

P

E

C

P

... 1

Reasons for Which Cardiac Assessment Is Sought ... 2

Cardiac Symptoms and Their Appraisal ... 2

Generation of Working List of Possible Diagnoses ... 4

Focused Physical Examination: Clinical Exercise ... 6

Focused Physical Examination: Practical Points ... 14

C

2 A

P

... 15

Physiology of the Arterial Pulse ... 15

Assessment of the Arterial Pulse ... 34

Practical Points in the Clinical Assessment of the Arterial Pulse ... 44

References ... 46

C

3 B

P

I

M

... 49

Physiology of Blood Flow and Blood Pressure ... 49

Physiology of Blood Pressure Measurement ... 50

Points to Remember When Measuring Blood Pressure ... 52

Factors That Affect Blood Pressure Readings ... 53

Interpretation of Blood Pressure Measurements ... 54

Use of Blood Pressure Measurement in Special Clinical Situations ... 56

References ... 64

C

4 J

V

P

... 67

Normal Right Atrial Pressure Pulse Contours ... 68

Jugular Venous Inflow Velocity Patterns and the Relationship to the Right Atrial Pressure Pulse ... 70

Jugular Venous Flow Events and Their Relationship to Jugular Venous Pulse Contours ... 74

Normal Jugular Venous Pulse Contour and Its Recognition at the Bedside ... 81

Individual Components of the Right Atrial Pressure Pulse, Their Determinants, and Their Recognition in the Jugulars ... 82

Abnormal Jugular Venous Pulse Contours as Related to Abnormal Jugular Venous Flow Velocity Patterns ... 92

Abnormal Jugular Contours ... 96

Assessment of Jugular Venous Pressure ... 105

Clinical Assessment of the Jugular Venous Pulse ... 107

References ... 110

xii Contents

C

5

P

P

... 113

Mechanics and Physiology of the Normal Apical Impulse ... 113

Physical Principles Governing the Formation of the Apical Impulse ... 115

Normal Apical Impulse and Its Determinants ... 118

Assessment of the Apical Impulse ... 120

Left Parasternal and Sternal Movements ... 133

Right Parasternal Movement ... 134

Pulsations Over the Clavicular Heads ... 134

Pulsations Over the Second and/or Third Left Intercostal Spaces ... 135

Subxiphoid Impulse ... 135

Practical Points in the Clinical Assessment of Precordial Pulsations ... 136

References ... 138

C

6 H

S

... 141

Principles of Sound Formation in the Heart ... 141

First Heart Sound (S1) ... 142

Clinical Assessment of S1 and Components ... 156

Second Heart Sound (S2) ... 158

Normal S2 ... 159

Abnormal S2 ... 162

Clinical Assessment of S2 ... 174

Opening Snap (OS) ... 179

Third Heart Sound (S3) ... 185

Clinical Assessment of S3 ... 198

Fourth Heart Sound (S4) ... 200

Clinical Assessment of S4 ... 204

References ... 206

C

7 H

M

: P

Principles Governing Murmur Formation ... 211

Hemodynamic Factors and Cardiac Murmurs ... 214

Frequencies of Murmurs ... 214

Grading of Murmurs ... 216

Systolic Murmurs ... 216

Ejection Murmurs ... 217

Regurgitant Systolic Murmurs ... 232

Mitral Regurgitation ... 233

Tricuspid Regurgitation ... 253

Ventricular Septal Defect (VSD) ... 258

Clinical Assessment of Systolic Murmurs ... 265

References ... 269

C

8 H

M

: P

Diastolic Murmurs ... 275

Diastolic Murmurs of Mitral Origin ... 275

Diastolic Murmurs of Tricuspid Origin ... 282

Semilunar Valve Regurgitation ... 283

Aortic Regurgitation ... 283

Pulmonary Regurgitation ... 290

Clinical Assessment of Diastolic Murmurs ... 292

Continuous Murmurs ... 294

Persistent Ductus Arteriosus ... 296

Aorto-Pulmonary Window ... 298

Sinus of Valsalva Aneurysm ... 298

Coronary Arteriovenous Fistulae ... 299

Venous Hum ... 300

Mammary Souffle ... 300

Clinical Assessment of Continuous Murmurs ... 300

Pericardial Friction Rub ... 302

Innocent Murmurs ... 303

References ... 304

C

9 E

A

... 309

The Stethoscope ... 309

Auscultation Method ... 310

References ... 318

C

10 P

B

S

S

C

D

... 321

Pathophysiology of Mitral Regurgitation ... 321

Pathophysiology of Aortic Regurgitation ... 325

Pathophysiology of Mitral Stenosis ... 329

Pathophysiology of Aortic Stenosis ... 331

Pathophysiology of Myocardial Ischemia/Infarction ... 334

Pathophysiology of Hypertensive Heart Disease ... 336

Pathophysiology of Dilated Cardiomyopathy ... 338

Pathophysiology of Hypertrophic Obstructive Cardiomyopathy ... 340

Pathophysiology of Atrial Septal Defect ... 342

Pathophysiology of Diastolic Dysfunction ... 345

Pathophysiology of Constrictive Pericarditis ... 347

Pathophysiology of Cardiac Tamponade ... 348

Appendix ... 351

References ... 356

C

11 L

S

M

C

D

... 361

General Observations ... 361

Congenital Syndromes/Diseases ... 364

Vascular Diseases ... 369

Valvular Heart Disease ... 372

Endocrine and Metabolic Diseases ... 373

Inflammatory Diseases ... 377

Diseases of Connective Tissue and Joints ... 377

Pharmacological Agents ... 381

Musculoskeletal Diseases ... 384

Tumors ... 386

Synopsis ... 386

Acknowledgment ... 390

References ... 390

Index ... 397

About the Authors ... 413

Contents xiii

C ^OMPANION CD

Contents

Jugular Venous Pulse Precordial Pulsations Heart Sounds

Heart Murmurs (Part 1) Heart Murmurs (Part 2)

The Companion CD is playable on any up-to-date Mac or Windows computer or laptop. Just insert in the CD Drive and the program will launch itself. See Help on the CD for navigation and features.

Headphones are preferable for listening to the heart sounds as the effect is closer to using a stethoscope. Some of the heart sounds are quite faint and it may be necessary to adjust the audio volume to hear them properly.

System and Software Recommendations Microsoft Windows^® 2000 or XP

Pentium^® III 500 or faster processor

At least 128 MB RAM (256 MB recommended) Soundcard and speakers or headphones

8X or faster CD-ROM drive

1024 x 768 monitor resolution or higher True Color display recommended Macintosh^® OS X (10.2 or higher)

At least 128 MB RAM (256 MB recommended) Soundcard and speakers or headphones

8X or faster CD-ROM drive

1024 x 768 monitor resolution or larger True Color display recommended

Acknowledgment

Mr. Roger Harris, head of the audiovisual department at St. Joseph’s Health Centre, was instrumental in the development of the CD.

xv

C ^OLOR P ^LATES

Color Plates follow p. 270.

COLOR PLATE 1 Fig. 1A,B, Chapter 7: Two-dimensional echocardiographic images with Doppler color flow mapping from a normal subject in the apical four-chamber view taken in diastole (A) and systole (B). See complete caption and discussion on p. 212.

COLOR PLATE 2 Fig. 2, Chapter 7: Two-dimensional echocardiographic images and Doppler color flow mapping from a patient with mitral regurgitation taken in the parasternal long axis. See complete caption and discussion on p. 213.

COLOR PLATE 3 Fig. 7B, Chapter 7: Doppler color flow image showing turbulent flow across the left ventricular outflow, in apical four-chamber view. See complete caption on p. 223 and discussion on p. 222.

COLOR PLATE 4 Fig. 12A,D, Chapter 7: Two-dimensional echocardiographic images in the parasternal view from a patient with hypertrophic obstructive cardio- myopathy with severe subaortic obstruction. The diastolic frame (A) shows the open mitral valve allowing the inflow from the left atrium (LA) into the left ventricle (LV). In (D), turbulent outflow as well as some mitral regurgitation. See complete caption and discussion on p. 226.

COLOR PLATE 5 Fig. 3, Chapter 11: Osler–Weber–Rendu syndrome. See complete caption on p. 367 and discussion on p. 365.

COLOR PLATE 6 Fig. 6, Chapter 11: Eruptive xanthoma. Skin lesions over back and chest resemble acne. See complete caption on p. 370 and discussion on p. 369.

COLOR PLATE 7 Fig. 7, Chapter 11: Mitral facies and malar flush in 35-yr-old woman with mitral stenosis and mitral regurgitation. See complete caption and discussion on p. 373.

COLOR PLATE 8 Fig. 12A, Chapter 11: Janeway lesions in infective endocarditis in a 50-yr- old drug addict. See complete caption on p. 378 and discussion on p. 377.

COLOR PLATE 9 Fig. 13A, Chapter 11: Mixed connective tissue diseases: patient with mask facies with puckering of skin around lips and malar depigmentation. See complete caption and discussion on p. 379.

COLOR PLATE 10 Fig. 17, Chapter 11: Amiodarone skin toxicity. See complete caption and discussion on p. 383.

xvii