Am I okay to go on holiday, doctor?

Around this time of year many of my cardiac patients ask me whether they can arrange a holiday. Some patients are worried about their fitness to fly, others are concerned about arranging travel insurance. In this blog, I'll highlight some useful resources to help answer these questions:

Fitness to fly

The British Cardiovascular Society has published a useful report to help clinicians advise their patients about fitness to fly. Entitled Fitness to fly for passengers with cardiovascular disease, the report can be accessed from the BCS website (click here) and contains a quick-reference guide that covers common cardiac conditions, together with a more detailed review of the evidence.

BCS report on Fitness to Fly (extract)

More generally, the UK Civil Aviation Authority has an online guide on fitness to fly for passengers and healthcare professionals, entitled Am I Fit to Fly?

Travel insurance

Obtaining travel insurance when patients have a cardiovascular condition can sometimes prove challenging. The British Heart Foundation covers this issue on their website (click here), and they also provide a list of sympathetic insurance companies.

Specific conditions

A number of websites provide information on fitness to travel for various cardiovascular conditions. These include:

• Arrhythmias
• Cardiomyopathy
• Heart Failure

Finally, NHS Scotland provides a public access website called Fit for Travel which provides travel health information for people travelling abroad from the UK.

Making sense of murmurs: The Levine scale

When we auscultate a systolic heart murmur, we need to describe its loudness or intensity. Some people use descriptive terms like 'soft' or 'loud', but traditionally the loudness of systolic murmurs is graded on a scale of 1 to 6. But what do the numbers mean?

The numeric system is sometimes called the Levine scale, named for Samuel A. Levine who first described it in 1933. The numbers correspond to the following intensities of murmur:

The Levine scale of systolic murmur intensity

In his original paper, Levine said that once physicians had worked with him for a short time, their gradings differed by no more than one gradation, and indeed were in "absolute agreement" in the majority of cases.

You can read more about Levine's grading of murmurs in the following paper:

Silverman ME, Wooley CF. Samuel A. Levine and the history of grading systolic murmurs. Am J Cardiol 2008; 102: 1107-1110.

You can also find Levine's original paper from 1933 here:

Levine SA. The systolic murmur: its clinical significance. JAMA 1933; 101: 436–438.

Samuel Levine was also, incidentally, the same physician who co-described Lown-Ganong-Levine syndrome, and also described Levine's sign.

Making sense of the apex beat

Palpation of the apex beat to assess its location and character is one of the key elements of a cardiovascular examination. However the terminology can cause confusion - after all, what exactly is a 'heaving' apex beat, and how does it differ from a 'thrusting' apex beat? Let's see if we can simplify and clarify things a bit.

It's possible to categorize 8 distinct types of apex beat:

The eight types of apex beat

Normal apex beat: This is the easy one. Located in the fifth intercostal space, in the mid-clavicular line, the normal apex beat has a relatively gentle pulsation.

Normal but shifted apex beat: Here the apex beat is normal in character, but its location is displaced because the heart itself has moved as a result of mediastinal shift, for instance due to tension pneumothorax. Remember to check for any tracheal deviation in the suprasternal notch. Another (extreme) example of a 'shifted' apex beat is when the patient has dextrocardia. In this case, the apex beat will be normal in character but impalpable on the patient's left, but it will be palpable on their right.

Impalpable apex beat: The apex beat may be impalpable because of hyperinflated lungs (COPD), high body mass index, or pericardial effusion.

Pressure-loaded apex beat: When there is left ventricular hypertrophy due to pressure overload on the left ventricle (e.g. hypertension, severe aortic stenosis), the apex beat is localized (i.e. not diffuse), undisplaced, and has a forceful character. This is sometimes also called a 'heaving' and 'sustained' apex beat, but I find these terms vague and open to interpretation.

Volume-loaded apex beat: In contrast to a pressure-loaded apex beat, a volume-loaded apex beat is diffuse (palpable over a larger area), displaced inferiorly and laterally, and has a less forceful character. This is sometimes called a 'non-sustained' apex beat. Examples include severe mitral or aortic regurgitation, which place the ventricle under volume overload.

Tapping apex beat: This describes the palpable first heart sound in mitral stenosis.

Double-impulse apex beat: Here there are two beats felt during each systole, and this is found in hypertrophic cardiomyopathy.

Dyskinetic apex beat: This describes an uncoordinated and diffuse apex beat seen with a left ventricular apical aneurysm.

As with all clinical skills, practice makes perfect. So assess the apex beat whenever you perform a cardiovascular system examination, and categorize your findings into one of the eight groups above.

To learn more about examination of the cardiovascular system (and other body systems), check out Chamberlain's Symptoms and Signs in Clinical Medicine, which I co-edited with David Gray.