Hypertrophic cardiomyopathy physical examination

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2]

There are numerous findings on physical examination that allow one to distinguish hypertrophic cardiomyopathy from other conditions such as aortic stenosis. On physical examination, (as shown in the table below) maneuvers that decrease left ventricular filling augment the murmur and maneuvers that increase afterload or filling decrease the murmur.

• The physical findings of HCM are associated with the dynamic outflow obstruction that is often present with this disease.^{[1][2][3][4][5] [6][7][8][9]}

• Patients with hypertrophic cardiomyopathy usually appear normal.

• Tachycardia with regular pulse or (ir)regularly irregular pulse
• Patients with hypertrophic cardiomyopathy are prone to arrhythmia

• Skin examination of patients with hypertrophic cardiomyopathy is usually normal.

• HEENT examination of patients with hypertrophic cardiomyopathy is usually normal.

• Jugular venous distension
  • “A wave” is prominent on JVP.
  • When CHF develops JVP is more prominent and Hepatojugular reflux might be present.
• Carotid
• Double carotid arterial pulse may be present.

• Pulmonary examination of patients with hypertrophic cardiomyopathy is usually normal.

• If dynamic outflow obstruction exists, physical examination findings that can be elicited include the pulsus bisferiens and the double apical impulse with each ventricular contraction. These findings, when present, can help differentiate HCM from aortic stenosis.
• In addition, if the individual has premature ventricular contractions (PVCs), the change in the carotid pulse intensity in the beat after the PVC can help differentiate HCM from aortic stenosis.
• In individuals with HCM, the pulse pressure will decrease in the beat after the PVC, while in aortic stenosis, the pulse pressure will increase.

• Powerful apical precordial impulse is present which may be shifted laterally.

• S1 is normal.
• There may be paradoxically split S2 in severe cases
• S3 gallop or S4 may also be present.
• S2 is louder in HCM than aortic stenosis.

• The murmur is characteristically a crescendo-decrescendo systolic murmur.
• Best heard between the apex and left sternal border.
• It radiates to the suprasternal notch but not to the carotid arteries or neck thus differentiating it from aortic stenosis.
• The cardiac murmur of HCM will sound similar to the murmur of aortic stenosis. However, this murmur will:

• increase in intensity with any maneuver that decreases the volume of blood in the left ventricle (such as standing, valsalva maneuver, amyl nitrate, diuretic administration or vasodilator administration).
• decrease in intensity with any maneuver that increases the volume of blood in the left ventricle (such as Mueller maneuver, squatting or handgrip).

• Hypertrophic cardiomyopathy(HCM) can be differentiated from aortic stenosis by the fact that the murmur of aortic stenosis does not change substantially with maneuvers.
• The character of the pulse in aortic stenosis is parvus et tardus, while a bisferiens pulse is noted in HCM.
• Associated murmurs:

• 10% of the patients with HCM will also present with aortic regurgitation and in that case, a diastolic decrescendo murmur may be present.
• If mitral regurgitation coexists with HCM then a holosystolic murmur will be beast heard at the caridac apex and left axilla.

• Abdominal examination of patients with hypertrophic cardiomyopathy is usually normal.

• Back examination of patients with hypertrophic cardiomyopathy is usually normal.

• Genitourinary examination of patients with hypertrophic cardiomyopathy is usually normal.

• Neuromuscular examination of patients with hypertrophic cardiomyopathy is usually normal.

• Extremities examination of patients with hypertrophic cardiomyopathy is usually normal.

• If they develop heart failure the followings might be observed:

• Clubbing
• Cyanosis
• Pitting/non-pitting edema of the upper/lower extremities

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