Physical diagnosis of coronary artery disease and its sequelae.

Abstract

ABSTRACT:Physical examination tends to be regarded negatively in the diagnosis of coronary artery disease (CAD). A resurgence of current interest in the physical diagnosis of CAD and its sequelae results from the availability of surgical techniques for their treatment and is made possible by a systemic clinical‐physiological‐angiographical correlative approach. An accentuated first sound (S1) in association with presystolic and diastolic gallops in the absence of congestive heart failure is highly suggestive of papillary muscle dysfunction (PMD) and/or ventricular aneurysm (VA), two of the most common sequelae of CAD. When S1 in VA is not accentuated, mural thrombosis should be suspected. The murmurs of PMD are much more common in CAD than generally believed and can be either ejection‐type, early systolic, midsystolic, pansystolic, or late systolic. A late systolic murmur (LSM) in CAD represents a mild form of PMD and may be distinguished from the murmur of the “auscultatory‐electrocardiographic” syndrome by its responses to amyl nitrite and the squatting position. Murmurs of PMD can be differentiated from other mitral regurgitant murmurs by their changing configurations, post‐extrasystolic diminution and inspiratory accentuation. Paradoxical splitting of the second sound in CAD is more an auscultatory illusion than an actual reversal of the sequence of closure of the aortic and pulmonic valves. Diastolic murmurs in CAD may be due to either VA or segmental coronary artery stenosis. It is concluded that physical examination gives valuable clues to the existence of CAD or its sequelae and to the functional status of the underlying myocardium. It constitutes the single most useful non‐invasive tool available to every physician.