How to instruct a patient with Hypertrophic Cardiomyopathy (HCM) to perform a squat to assess for a murmur?

From the Guidelines

To assess a patient's murmur in hypertrophic cardiomyopathy (HCM), instruct them to squat while you listen to their heart sounds, as this maneuver helps evaluate the severity of outflow tract obstruction, which is crucial for symptom management and risk assessment, as recommended by the 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR guideline 1. When asking a patient to squat for murmur assessment in HCM, first explain that this maneuver helps evaluate their heart murmur.

• Say something like: "I'd like you to perform a quick squatting exercise to help me better assess your heart sounds.
• Please stand comfortably, then lower your body into a squatting position by bending your knees while keeping your back straight.
• Hold this position for about 10-15 seconds while I listen to your heart, then slowly stand back up when I indicate." Ensure the patient has something to hold onto for balance if needed. During the squat, the systolic murmur of HCM typically decreases in intensity because squatting increases venous return and afterload while expanding the left ventricular cavity, which reduces the outflow tract obstruction, as noted in the 2024 guideline 1. When the patient stands up, listen carefully as the murmur often becomes more prominent again. This dynamic auscultation technique is valuable because it helps distinguish HCM from other causes of systolic murmurs and provides information about the severity of outflow obstruction, which has implications for symptom management and risk assessment, as highlighted in the guideline 1. The 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR guideline emphasizes the importance of provocative maneuvers, such as squat-to-stand, in assessing LVOT gradients and outflow tract obstruction in patients with HCM 1.

From the Research

Asking a Patient to Squat for Murmur in HCM

To ask a patient to squat for murmur in Hypertrophic Cardiomyopathy (HCM), consider the following steps:

• Explain the purpose of the maneuver to the patient, ensuring they understand that squatting can help assess the presence and characteristics of a murmur associated with HCM 2.
• Instruct the patient to stand with their feet shoulder-width apart and then squat down, keeping their back straight and their knees behind their toes.
• During the squatting maneuver, auscultate the patient's heart sounds to assess for changes in the murmur, as squatting can increase venous return and potentially affect the intensity of the murmur.
• Consider the patient's overall health and ability to perform the squatting maneuver safely, as patients with HCM may have exercise limitations or other comorbidities that need to be taken into account 3, 4.

Key Considerations

• The squatting maneuver is a physical examination technique used to assess the presence and characteristics of a murmur in patients with suspected HCM.
• The maneuver can help differentiate HCM from other causes of murmur, as the intensity of the murmur may change with squatting.
• Patients with HCM may require individualized instruction and monitoring during the squatting maneuver to ensure their safety and comfort 5, 6.
• The use of medications such as beta blockers or calcium channel blockers may also affect the patient's response to the squatting maneuver and should be considered when interpreting the results 3, 4.