Handgrip and murmur intensity - USMLE Forums
USMLE Forums Logo
USMLE Forums         Your Reliable USMLE Online Community     Members     Posts
Home
USMLE Articles
USMLE News
USMLE Polls
USMLE Books
USMLE Apps
Go Back   USMLE Forums > USMLE Step 1 Forum

USMLE Step 1 Forum USMLE Step 1 Discussion Forum: Let's talk about anything related to USMLE Step 1 exam


Reply
 
Thread Tools Search this Thread Display Modes
  #1  
Old 02-28-2013
drcalikila's Avatar
USMLE Forums Scout
 
Steps History: 1 + CS
Posts: 53
Threads: 19
Thanked 6 Times in 5 Posts
Reputation: 16
Stethoscope Handgrip and murmur intensity

According to FA 2013, if a patient hand grips - the intensity increases for MR, AR, VSD and MVP murmurs. In MTB, it says handgrip decreases the intensity of MVP. Which one is correct? Can someone explain why AR, MR, VSD and MVP increase in intensity? Is there a better way of remembering this? Thanks!!!
Reply With Quote Quick reply to this message



  #2  
Old 02-28-2013
dr.ali2011's Avatar
USMLE Forums Scout
 
Steps History: Not yet
Posts: 96
Threads: 10
Thanked 24 Times in 23 Posts
Reputation: 34
Send a message via Skype™ to dr.ali2011
Default

Quote:
Originally Posted by drcalikila View Post
According to FA 2013, if a patient hand grips - the intensity increases for MR, AR, VSD and MVP murmurs. In MTB, it says handgrip decreases the intensity of MVP. Which one is correct? Can someone explain why AR, MR, VSD and MVP increase in intensity? Is there a better way of remembering this? Thanks!!!
It is simple man, as u make a fist or you tie a blood pressure cuff around the artery, you increases the resistance ahead of the left side of the heart, so every sound on the left side of the heart will intensify
__________________
If you do not hope, you will not find what is beyond your hopes.
Reply With Quote Quick reply to this message
The above post was thanked by:
drcalikila (02-28-2013)
  #3  
Old 02-28-2013
USMLE Forums Veteran
 
Steps History: CS Only
Posts: 219
Threads: 44
Thanked 44 Times in 33 Posts
Reputation: 54
Default

here's how i think it works:

hand grip will increase the TPR so blood will be forced to 'not to go' via that high resistance and will go via the AV valves.. it'll worsen (increase the intensity) of backward flow murmurs ( regurgitations of the aortic and mitral .. and also MVP_kinda like MR_ and VSD)

and it will improve (decrease the intensity) of forward flow murmurs (since it's like as if correcting the defect) like stenosis of the aortic and mitral valves and HCM _kinda like AS)

so now we have 3 systolic murmurs: AS, HCM, MVP, to differentiate:
*HCM and MVP: by the presence of the click in MVP, and that hand grip will intensify MVP

*HCM and AS: by increasing left ventricular volume: it'll intensify AS .. and will decrease HCM (because increase lt ventricular volume will stretch the ventricule > decrease the obstruction of HCM )..

another note from a bates (guide to physical examination)
squatting > increase tpr and lt vent volume > 1)MVP: delay the click, shorten the murmur and decreases it 2) also decrease murmur of HCM

hope i'm correct.. if not add/change anything ... and can someone please explain why increase lt vent vol would decrease the murmur of MVP

source:
-my studying
-this thread (altho i found it confusing and some conflicting posts)
http://www.usmle-forums.com/usmle-st...t-murmurs.html
-http://en.wikipedia.org/wiki/Mitral_valve_prolapse#Murmur (murmur section)

Last edited by Faith-USMLE; 02-28-2013 at 08:19 AM.
Reply With Quote Quick reply to this message
The above post was thanked by:
drcalikila (02-28-2013), dreamgirl (12-01-2014), faisalahmed518 (09-21-2014), maymed (06-09-2014)
 
  #4  
Old 02-28-2013
USMLE Forums Veteran
 
Steps History: Not yet
Posts: 213
Threads: 54
Thanked 53 Times in 41 Posts
Reputation: 63
Default

Mitral valve prolapse =/= mitral rigurtation

Rigurtation can and cannot cause prolapse.

I rmemeber step up to medicine explained this. Hoho.
Reply With Quote Quick reply to this message
The above post was thanked by:
drcalikila (02-28-2013)
  #5  
Old 02-28-2013
USMLE Forums Scout
 
Steps History: ---
Posts: 75
Threads: 12
Thanked 63 Times in 33 Posts
Reputation: 73
Default

I really like your explanations. Short & to the point! =)

I want to "attempt" ...to correct this statement...based on the findings from the below links. If my understanding is wrong, feel free to correct me.

Quote:
Originally Posted by ` Faith ` View Post

*HCM and AS: by increasing left ventricular volume: it'll intensify AS .. and will decrease HCM (because increase lt ventricular volume will stretch the ventricule > decrease the obstruction of HCM )..
AS = aortic stenosis

- Handgrip decreases both the murmurs in HCM & AS.

- Aortic stenosis (AS) is a disease of the heart valves in which the opening of the aortic valve is narrowed. In patient with aortic stenosis, they have problem ejecting blood out to the periphery during systole.

- Handgrip decreases ejection of blood by increasing afterload (through the compression of the arteries of the arm) and it has no effect on venous return, thus handgrip improves (lessens) AS murmur (decreased outflow).
- Handgrip softens the murmurs of aortic stenosis by preventing blood from leaving the ventricles; you canít eject blood from LV & the AS murmur will soften.
- Another way of saying it is that the murmur of AS is based on the gradient between the LV & aorta.
- If the LV pressure is greater than the aorta pressure, then the gradient or difference is high.
- The higher the gradient, the louder the murmur & the more severe the AS is considered.
- Handgrip increases pressure in the aorta; therefore, the gradient or difference between the LV &
aorta decreases.
- handgrip is like covering a thrombone or trumpet.
- You canít produce music if you put a hand over the front of a wind instrument.


What are the effects of handgrip and squatting on Aortic stenosis ?

http://books.google.com/books?id=07P...enosis&f=false

http://en.wikipedia.org/wiki/Handgrip_maneuver

http://cmbi.bjmu.edu.cn/uptodate/car...d%20sounds.htm
Reply With Quote Quick reply to this message
The above post was thanked by:
drcalikila (02-28-2013), dreamgirl (12-01-2014)
  #6  
Old 02-28-2013
USMLE Forums Veteran
 
Steps History: CS Only
Posts: 219
Threads: 44
Thanked 44 Times in 33 Posts
Reputation: 54
Default

Quote:
Originally Posted by luschka View Post

- Handgrip decreases both the murmurs in HCM & AS.
[/URL]
i'm a bit confused about what you're saying

the above statement we both agree on (handgrip decreases murmur of HCM and AS)

the statement you quoted from my post was about increasing left ventricular blood volume (by squatting for eg) to differentiate AS from HCM..

again please explain if that's still wrong.. and why increased left ventricular volume would decrease MVP's murmur ?
Reply With Quote Quick reply to this message
  #7  
Old 02-28-2013
USMLE Forums Scout
 
Steps History: ---
Posts: 75
Threads: 12
Thanked 63 Times in 33 Posts
Reputation: 73
Default

This is your statement:

"*HCM and AS: by increasing left ventricular volume: it'll intensify AS .. and will decrease HCM (because increase lt ventricular volume will stretch the ventricule > decrease the obstruction of HCM )."

You stated that handgrip will "intensify AS". I disagree, I'm saying that increasing left ventricular volume by handgrip will decrease the murmur of HCM & also decrease the murmur of AS.

----

- For HOCM, since handgrip decreases ventricular emptying (retaining more blood in the ventricle, less emptying)..increasing ventricular volume will stretch the ventricle → it lessens the obstruction in HOCM and decreases the murmur.

----

- Handgrip decreases ejection of blood by increasing afterload (through the compression of the arteries of the arm) and it has no effect on venous return, thus handgrip improves (lessens) AS murmur (decreased outflow).
- Handgrip softens the murmurs of aortic stenosis by preventing blood from leaving the ventricles; you canít eject blood from LV & the AS murmur will soften.
- Another way of saying it is that the murmur of AS is based on the gradient between the LV & aorta.
- If the LV pressure is greater than the aorta pressure, then the gradient or difference is high.
- The higher the gradient, the louder the murmur & the more severe the AS is considered.
- Handgrip increases pressure in the aorta; therefore, the gradient or difference between the LV & aorta decreases.
- Handgrip is like covering a thrombone or trumpet.
- You canít produce music if you put a hand over the front of a wind instrument.

---

Please see the above links for further clarifications.
Reply With Quote Quick reply to this message
  #8  
Old 02-28-2013
USMLE Forums Scout
 
Steps History: ---
Posts: 75
Threads: 12
Thanked 63 Times in 33 Posts
Reputation: 73
Default

Handrip will decrease the murmur of MVP.

----

So, let's review the mechanism of handgrip again:

- Handgrip is a maneuver that increases afterload by compressing the arteries of the arm by contracting the muscles of the arm.

- Sustained (isometric) handgrip increases the systemic vascular resistance & thus reduces the gradient across the LV outflow tract. The handgrip maneuver increases afterload by squeezing the arterioles and increasing Total Peripheral Resistance.

- Thus, increase in TPR will cause blood to be retained on the arterial side of circulation and will increase the aortic pressure against which the heart must pump. As a result of this simultaneous change, both the cardiac output and the venous return are decreased.

----

- The murmur of Mitral valve prolapse lessen when the left ventricular chamber is larger or more full.
- What would happens to the size of the left ventricular (LV) chamber if there is increased afterload?
- The LV chamber will not empty & therefore, the LV will be larger.
- A large LV chamber relieves or lessens the obstruction in HOCM & Mitral valve prolapse
- Mitral valve prolapse is caused by a insufficient tension on chordae tendonae.
- Therefore MORE blood cases INCREASED tension and make the heart have LESS of a murmur.
- In other words, when the heart is FULL of blood because of increase preload or increase afterload then the chordae tendonae are not a problem because the volume of blood in the heart is doing the work for them.
- Therefore, the murmur becomes LESS and LATER.
- Increase TPR means a longer phase of isovolumetric contraction.
- This means the heart stays full of blood longer and it the chordae tendonae have help for longer, which makes the heart seem more normal and move it closer to S2.
Reply With Quote Quick reply to this message
The above post was thanked by:
drcalikila (02-28-2013), Taayseer (09-20-2014)
  #9  
Old 02-28-2013
USMLE Forums Addict
 
Steps History: Not yet
Posts: 135
Threads: 3
Thanked 73 Times in 48 Posts
Reputation: 83
Default

Quote:
why increased left ventricular volume would decrease MVP's murmur ?
It's because the ventricular cavity is enlarged with increased volume. Think of the chordae tendinae between the ventricular papillary muscles and the valve leaflets as a string with a fixed length. When the distance between the papillary muscle and valve leaflet is small (a small ventricular cavity), the string is loose and the valves prolapse early in systole (as the heart contracts and the cavity is made even smaller) and produce a longer murmur as the hearts continues to contract and empty. Basically the prolapse happens relatively earlier.

But if the ventricular volume was increased, that means the ventricular cavity is made larger. This increases the distance b/w the papillary muscle and valve leaflet (due to the larger ventricular cavity), so it takes 'til late systole/contraction (as a lot more blood is pumped out before the cavity gets small enough) for the chordae tendinae to be loose enough to allow the leaflet to prolapse. So in this case the murmur produced will be both weaker and shorter in duration as it's almost at the end of systole.

This is just an oversimplification, but I believe it serves the point.
__________________

To view links or images in signatures your post count must be 10 or greater. You currently have 0 posts.
You can't confuse the confused!
To view links or images in signatures your post count must be 10 or greater. You currently have 0 posts.
Reply With Quote Quick reply to this message
The above post was thanked by:
drcalikila (02-28-2013), Faith-USMLE (02-28-2013), maymed (06-09-2014), Taayseer (09-20-2014), voicesinmyhead (11-19-2015)
  #10  
Old 02-28-2013
USMLE Forums Veteran
 
Steps History: CS Only
Posts: 219
Threads: 44
Thanked 44 Times in 33 Posts
Reputation: 54
Default

Thanks slow poke for the explanation.. makes lots of sense!!

Quote:
Originally Posted by luschka View Post
This is your statement:

"*HCM and AS: by increasing left ventricular volume: it'll intensify AS .. and will decrease HCM (because increase lt ventricular volume will stretch the ventricule > decrease the obstruction of HCM )."

You stated that handgrip will "intensify AS". I disagree, I'm saying that increasing left ventricular volume by handgrip will decrease the murmur of HCM & also decrease the murmur of AS.

----

- For HOCM, since handgrip decreases ventricular emptying (retaining more blood in the ventricle, less emptying)..increasing ventricular volume will stretch the ventricle → it lessens the obstruction in HOCM and decreases the murmur.

----

- Handgrip decreases ejection of blood by increasing afterload (through the compression of the arteries of the arm) and it has no effect on venous return, thus handgrip improves (lessens) AS murmur (decreased outflow).
- Handgrip softens the murmurs of aortic stenosis by preventing blood from leaving the ventricles; you can’t eject blood from LV & the AS murmur will soften.
- Another way of saying it is that the murmur of AS is based on the gradient between the LV & aorta.
- If the LV pressure is greater than the aorta pressure, then the gradient or difference is high.
- The higher the gradient, the louder the murmur & the more severe the AS is considered.
- Handgrip increases pressure in the aorta; therefore, the gradient or difference between the LV & aorta decreases.
- Handgrip is like covering a thrombone or trumpet.
- You can’t produce music if you put a hand over the front of a wind instrument.

---

Please see the above links for further clarifications.
hope this discussion will help make the info stick in our minds ^^"

first.. my comment was about increasing the left ventricular volume 'alone' by leg raising for eg.. witch would differentiate AS from HCM ..

as for hand grip we both agree that it'll decrease the intensity of both HCM and AS: it'll increase the TPR and it's effect is to increase (make worse) for regurgitant blood (AR and MR) and MVP_backward flows.. but it'll decrease (improve) murmurs due to forward flow: stenosis (AS and MS) ahd HCM.. and on that we both agree..
the point is, hand grip would mostly increase the TPR (not the venous return) as it's stated on your link (second line):
http://books.google.com/books?id=07P...enosis&f=false

not sure.. but the texts i've highlighted above with red.. seem conflicting to me and causing me some confusion.. if you say hand grip increases venous return for HCM.. how come it has no effect on venous return when we're talking about AS
Reply With Quote Quick reply to this message
  #11  
Old 02-28-2013
USMLE Forums Veteran
 
Steps History: CS Only
Posts: 219
Threads: 44
Thanked 44 Times in 33 Posts
Reputation: 54
Default

Murmur of Aortic Stenosis versus Hypertrophic Obstructive CardioMyopathy

nice simple threat.. it has a link in it too
Reply With Quote Quick reply to this message
  #12  
Old 09-20-2014
USMLE Forums Scout
 
Steps History: 1+CK+CS
Posts: 14
Threads: 1
Thanked 9 Times in 6 Posts
Reputation: 19
Thumbs Up Thanks!

Doctors I really have to say thank you for this fabulous explanation. I have read so many books and solved a lot of questions, however I have never passed through something like this!

Keep up the good work...
Reply With Quote Quick reply to this message
The above post was thanked by:
voicesinmyhead (11-19-2015)



Reply

Tags
Audio-, Clinical-Signs

Quick Reply
Message:
Options

Register Now

In order to be able to post messages on the USMLE Forums forums, you must first register.
Please enter your desired user name, your email address and other required details in the form below.
User Name:
Password
Please enter a password for your user account. Note that passwords are case-sensitive.
Password:
Confirm Password:
Email Address
Please enter a valid email address for yourself.
Email Address:
Medical School
Choose "---" if you don't want to tell. AMG for US & Canadian medical schools. IMG for all other medical schools.
USMLE Steps History
What steps finished! Example: 1+CK+CS+3 = Passed Step 1, Step 2 CK, Step 2 CS, and Step 3.

Choose "---" if you don't want to tell.

Favorite USMLE Books
What USMLE books you really think are useful. Leave blank if you don't want to tell.
Location
Where you live. Leave blank if you don't want to tell.

Log-in

Human Verification

In order to verify that you are a human and not a spam bot, please enter the answer into the following box below based on the instructions contained in the graphic.



Thread Tools Search this Thread
Search this Thread:

Advanced Search
Display Modes


Similar Threads
Thread Thread Starter Forum Replies Last Post
Murmur Intensity with Respiration rasheed USMLE Step 2 CK Bits & Pieces 3 12-10-2014 07:24 PM
A murmur and widely split S2! Rawalian USMLE Step 2 CK Forum 11 08-26-2013 05:17 PM
15 Yr Old Immigrant with murmur? alex85 USMLE Step 2 CK Forum 17 04-16-2012 07:31 PM
What are the effects of handgrip and squatting on Aortic stenosis ? kemoo USMLE Step 2 CK Forum 1 06-18-2011 07:12 AM
Murmur of Mitral Regurgitation Xaquake USMLE Step 2 CK Forum 2 02-28-2010 10:11 AM

RSS Feed
Find Us on Facebook
vBulletin Security provided by vBSecurity v2.2.2 (Pro) - vBulletin Mods & Addons Copyright © 2017 DragonByte Technologies Ltd.

USMLE® & other trade marks belong to their respective owners, read full disclaimer
USMLE Forums created under Creative Commons 3.0 License. (2009-2014)