Special Maneuvers
Lecture 5 · Advanced Cardiovascular & Peripheral Vascular Examination · the class handout on maneuvers, as written
Instructional Objective
Advanced Cardiac and Peripheral Vascular System Medical History and Examination
- Demonstrate the proper clinical skills for maneuvers to evaluate murmurs.
Five maneuvers, three murmurs. Each maneuver changes how much blood returns to the heart (preload) or how hard the heart pumps against (afterload), and that changes how loud a murmur is. The handout tracks the same three conditions through every maneuver: aortic stenosis, mitral valve prolapse (MVP) and hypertrophic obstructive cardiomyopathy (HOCM). Sections 1–5 are the handout in its own order and wording; section 6 puts all five side by side.
1 · Valsalva
- Decreases left ventricular filling; increases intrathoracic pressure (decreases preload)
- Auscultation findings
- Decreases aortic stenosis
- Increases mitral valve prolapse (MVP)
- Increases hypertrophic obstructive cardiomyopathy (HOCM)
2 · Standing position
- Decreases venous return to the right and left ventricles (preload) and decreases systemic arterial pressure (afterload)
- Auscultation findings
- Decreases aortic stenosis
- Increases mitral valve prolapse (MVP)
- Increases hypertrophic obstructive cardiomyopathy (HOCM)
3 · Squatting position
- Increases venous return to heart (preload) and increases systemic arterial pressure (afterload)
- Auscultation findings
- Increases aortic stenosis
- Decreases mitral valve prolapse (MVP)
- Decreases hypertrophic obstructive cardiomyopathy (HOCM)
4 · Raised legs while in a supine position
- Increases venous return (preload) to the right and left ventricles
- Auscultation findings
- Increases aortic stenosis
- Decreases mitral valve prolapse (MVP)
- Decreases hypertrophic obstructive cardiomyopathy (HOCM)
5 · Sustained hand grip
- Increases systemic arterial pressure (afterload) and venous return (preload)
- Auscultation findings
- Decreases aortic stenosis
- Decreases mitral valve prolapse (MVP)
- Decreases hypertrophic obstructive cardiomyopathy (HOCM)
6 · All five at a glance
| Maneuver | Preload | Afterload | Aortic stenosis | Mitral valve prolapse (MVP) | Hypertrophic obstructive cardiomyopathy (HOCM) |
|---|---|---|---|---|---|
| Valsalva | Decreases | Not listed | Decreases | Increases | Increases |
| Standing position | Decreases | Decreases | Decreases | Increases | Increases |
| Squatting position | Increases | Increases | Increases | Decreases | Decreases |
| Raised legs, supine | Increases | Not listed | Increases | Decreases | Decreases |
| Sustained hand grip | Increases | Increases | Decreases | Decreases | Decreases |
“Not listed” means the handout does not state it for that maneuver.
What to notice when you read across. Aortic stenosis and hypertrophic obstructive cardiomyopathy move in opposite directions on every maneuver except hand grip: Valsalva and standing decrease aortic stenosis and increase hypertrophic obstructive cardiomyopathy; squatting and raised legs do the reverse. Mitral valve prolapse moves with hypertrophic obstructive cardiomyopathy every time. Sustained hand grip is the one that decreases all three.
7 · Checked against the lecture
The lecture deck covers the same maneuvers on slides 58–63 and agrees with the handout where they overlap:
- Valsalva (slide 61): forceful expiration against a closed airway raises intrathoracic pressure and decreases left ventricular filling (preload). The hypertrophic cardiomyopathy murmur increases; the aortic stenosis murmur gets softer or does not change.
- Standing quickly from a squatting position (slide 62): blood moves to the legs and less returns to the heart, which decreases left ventricular preload. The hypertrophic cardiomyopathy murmur becomes louder; the aortic stenosis murmur gets softer.
- Squatting from a standing position, or leg raise (slide 62): venous return and preload increase. The hypertrophic cardiomyopathy murmur gets softer, because the outflow obstruction lessens; the aortic stenosis murmur gets louder, because more blood rushes past the narrow valve. Mitral valve prolapse is moved later in systole.
Where the deck says more. On isometric hand grip (slide 63) the deck lists a different set of murmurs: it increases the systolic murmurs of mitral regurgitation, pulmonic stenosis and ventricular septal defect, and the diastolic murmurs of aortic regurgitation and mitral stenosis. The handout’s hand grip entry covers only aortic stenosis, mitral valve prolapse and hypertrophic obstructive cardiomyopathy, so the two lists complement each other rather than conflict.
On the maneuvers slide about hypertrophic obstructive cardiomyopathy (slide 60) the deck states, in capitals: “IMPORTANT TO LEARN THIS MURMUR SO YOU DON’T SIGN OFF INCORRECTLY ON A SPORTS PHYSICAL.” The deck also says the maneuvers help distinguish the murmurs of mitral valve prolapse and hypertrophic obstructive cardiomyopathy from aortic stenosis.