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Cardiovascular Examination

By

Jessica I. Gupta

, MD, Michigan Medicine at the University of Michigan;


Michael J. Shea

, MD, Michigan Medicine at the University of Michigan

Last full review/revision Apr 2021
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Topic Resources

Complete examination of all systems is essential to detect peripheral and systemic effects of cardiac disorders and evidence of noncardiac disorders that might affect the heart. Examination includes the following:

Cardiac auscultation Cardiac Auscultation Auscultation of the heart requires excellent hearing and the ability to distinguish subtle differences in pitch and timing. Hearing-impaired health care practitioners can use amplified stethoscopes... read more is discussed in a separate topic. Despite the ever-increasing use of cardiac imaging, bedside auscultation remains useful as it is always available and can be repeated as often as desired without cost.

Examination also includes the collection of other patient data.

Vital Signs

Vital signs include

  • Blood pressure

  • Heart rate and rhythm

  • Respiratory rate

  • Temperature

Additional data often obtained along with vital signs include patient weight and peripheral oxygen saturation (SpO2).

Blood pressure (BP) is measured in both arms and, for suspected congenital cardiac disorders or peripheral vascular disorders, in both legs. The bladder of an appropriately sized cuff encircles 80% of the limb’s circumference, and the bladder’s width is 40% of the circumference. The first sound heard as the mercury column falls is systolic pressure; disappearance of the sound is diastolic pressure (5th-phase Korotkoff sound). Up to a 15 mm Hg pressure differential between the right and left arms is normal; a greater differential suggests a vascular abnormality (eg, dissecting thoracic aorta) or a peripheral vascular disorder. Leg pressure is usually 20 mm Hg higher than arm pressure. To obtain an accurate blood pressure measurement, the patient should

  • Be seated in a chair (not on the examination table) for > 5 minutes, feet on floor, back supported

  • Have the limb supported at heart level with no clothing covering the area of cuff placement

  • Abstain from exercising, consuming caffeine, or smoking for at least 30 minutes before the measurement is taken

Heart rate and rhythm are assessed by palpating the carotid or radial pulse or by cardiac auscultation if arrhythmia Overview of Arrhythmias The normal heart beats in a regular, coordinated way because electrical impulses generated and spread by myocytes with unique electrical properties trigger a sequence of organized myocardial... read more Overview of Arrhythmias is suspected; some heartbeats during arrhythmias may be audible but do not generate a palpable pulse.

Weight is collected at each clinic visit with the patient on a standing scale and, ideally, while wearing a similar amount of clothing. In patients with heart failure, weight gain may indicate hypervolemia, while weight loss may indicate cardiac cachexia (unintentional, non-edematous weight loss of > 5% within the last 12 months—1 General reference Complete examination of all systems is essential to detect peripheral and systemic effects of cardiac disorders and evidence of noncardiac disorders that might affect the heart. Examination... read more General reference ). History History Symptoms or the physical examination may suggest a cardiovascular disorder. For confirmation, selected noninvasive and invasive cardiac tests are usually done. A thorough history is fundamental... read more and additional findings from the physical examination (jugular veins Neck veins Complete examination of all systems is essential to detect peripheral and systemic effects of cardiac disorders and evidence of noncardiac disorders that might affect the heart. Examination... read more Neck veins , lung and extremity examinations) are required to determine whether weight changes are related to changes in volume status and/or amount of muscle or fat.

Peripheral arterial oxygen saturation (SpO2)is obtained. Pulse oximetry measures the oxygen saturation of hemoglobin in arterial blood (SpO2) and serves as a rapid, noninvasive estimation of tissue oxygenation. Pulse oximetry is obtained by using a probe attached to a finger or earlobe. Overall consensus is that SpO2 95% is normal, whereas values < 95% suggest hypoxemia. A notable exception to this cutoff value is in patients with chronic obstructive pulmonary disease Chronic Obstructive Pulmonary Disease (COPD) Chronic obstructive pulmonary disease (COPD) is airflow limitation caused by an inflammatory response to inhaled toxins, often cigarette smoke. Alpha-1 antitrypsin deficiency and various occupational... read more Chronic Obstructive Pulmonary Disease (COPD) ; in these patients, the target SpO2 is 88 to 92%. When hypoxemia is present, potential cardiac etiologies include pulmonary edema Pulmonary Edema Pulmonary edema is acute, severe left ventricular failure with pulmonary venous hypertension and alveolar flooding. Findings are severe dyspnea, diaphoresis, wheezing, and sometimes blood-tinged... read more Pulmonary Edema in patients with heart failure and right-to-left intracardiac shunts (a patent foramen ovale in patients with pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension is increased pressure in the pulmonary circulation. It has many secondary causes; some cases are idiopathic. In pulmonary hypertension, pulmonary vessels become constricted... read more , congenital heart disease including tetralogy of Fallot Tetralogy of Fallot Tetralogy of Fallot consists of 4 features: a large ventricular septal defect, right ventricular outflow tract obstruction and pulmonic valve stenosis, right ventricular hypertrophy, and over-riding... read more Tetralogy of Fallot ).

Ankle-brachial index (ABI)

The ankle-brachial index (ABI) is the ratio of systolic blood pressure (BP) in the ankle to that in the arm. With the patient recumbent, the ankle blood pressure is measured in both the dorsalis pedis and posterior tibial artery, and the arm blood pressure is measured in both arms at the brachial artery. The index is calculated for each lower extremity by dividing the higher of the dorsalis pedis or posterior tibial pressure in that extremity by the higher of the 2 brachial artery systolic pressures. This ratio is normally > 1. A Doppler probe may be used to measure blood pressure at the ankle if the pedal pulses are not easily palpable.

Orthostatic changes

Blood pressure and heart rate are measured with the patient supine, seated, and standing; a 1-minute interval is needed between each change in position. A difference in blood pressure of 10 mm Hg and a change in heart rate of 20 beats per minute is normal; the difference in blood pressure tends to be a little greater in older patients due to loss of vascular elasticity.

Pulsus paradoxus

Normally during inspiration, systolic arterial blood pressure can decrease as much as 10 mm Hg, and pulse rate increases to compensate. An exaggeration of this normal response with a greater decrease in systolic blood pressure or weakening of the pulse during inspiration is considered pulsus paradoxus. Pulsus paradoxus occurs in

Blood pressure decreases during inspiration because negative intrathoracic pressure increases venous return and hence right ventricular (RV) filling; as a result, the interventricular septum bulges slightly into the left ventricular (LV) outflow tract, decreasing cardiac output and thus BP. This mechanism (and the drop in systolic BP) is exaggerated in disorders that cause high negative intrathoracic pressure (eg, asthma) or that restrict RV filling (eg, cardiac tamponade, cardiomyopathy) or outflow (eg, pulmonary embolism).

Pulsus paradoxus is quantified by inflating a BP cuff to just above systolic BP and deflating it very slowly (eg, 2 mm Hg/heartbeat). The pressure is noted when Korotkoff sounds are first heard (at first, only during expiration) and when Korotkoff sounds are heard continuously. The difference between the pressures is the “amount” of pulsus paradoxus.

General reference

Pulses

Peripheral pulses

Major peripheral pulses in the arms and legs are palpated for symmetry and volume (intensity). Elasticity of the arterial wall is noted. Absence of pulses may suggest an arterial disorder (eg, atherosclerosis Atherosclerosis Atherosclerosis is characterized by patchy intimal plaques (atheromas) that encroach on the lumen of medium-sized and large arteries; the plaques contain lipids, inflammatory cells, smooth muscle... read more Atherosclerosis ) or systemic embolism. Peripheral pulses may be difficult to feel in obese or muscular people. The pulse has a rapid upstroke, then collapses in disorders with a rapid runoff of arterial blood (eg, arteriovenous communication, aortic regurgitation Aortic Regurgitation Aortic regurgitation (AR) is incompetency of the aortic valve causing backflow from the aorta into the left ventricle during diastole. Causes include valvular degeneration and aortic root dilation... read more Aortic Regurgitation ). The pulse is rapid and bounding in hyperthyroidism Hyperthyroidism Hyperthyroidism is characterized by hypermetabolism and elevated serum levels of free thyroid hormones. Symptoms are many and include tachycardia, fatigue, weight loss, nervousness, and tremor... read more Hyperthyroidism and hypermetabolic states; it is slow and sluggish in hypothyroidism Hypothyroidism Hypothyroidism is thyroid hormone deficiency. It is diagnosed by clinical features such as a typical facial appearance, hoarse slow speech, and dry skin and by low levels of thyroid hormones... read more Hypothyroidism . If pulses are asymmetric, auscultation over peripheral vessels may detect a bruit due to stenosis.

Carotid pulses

Observation, palpation, and auscultation of both carotid pulses may suggest a specific disorder (see table Carotid Pulse Amplitude and Associated Disorders Carotid Pulse Amplitude and Associated Disorders Complete examination of all systems is essential to detect peripheral and systemic effects of cardiac disorders and evidence of noncardiac disorders that might affect the heart. Examination... read more Carotid Pulse Amplitude and Associated Disorders ). Aging and arteriosclerosis lead to vessel rigidity, which tends to eliminate the characteristic findings. In very young children, the carotid pulse may be normal, even when severe aortic stenosis is present.

Auscultation over the carotid arteries can distinguish murmurs from bruits. Murmurs originate in the heart or great vessels and are usually louder over the upper precordium and diminish toward the neck. Bruits are higher-pitched, are heard only over the arteries, and seem more superficial. An arterial bruit must be distinguished from a venous hum. Unlike an arterial bruit, a venous hum is usually continuous, heard best with the patient sitting or standing, and is eliminated by compression of the ipsilateral internal jugular vein.

Table
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Veins

Peripheral veins

The peripheral veins are observed for varicosities Varicose Veins Varicose veins are dilated superficial veins in the lower extremities. Usually, no cause is obvious. Varicose veins are typically asymptomatic but may cause a sense of fullness, pressure, and... read more Varicose Veins , arteriovenous malformations (AVMs) and shunts, and overlying inflammation and tenderness due to thrombophlebitis. An AVM or a shunt produces a continuous murmur (heard on auscultation) and often a palpable thrill (because resistance is always lower in the vein than in the artery during systole and diastole).

Neck veins

The neck veins are examined to estimate venous wave height and waveform. Height is proportional to right atrial pressure, and waveform reflects events in the cardiac cycle; both are best observed in the internal jugular vein.

The jugular veins are usually examined with the patient reclining at 45°. The top of the venous column is normally just above the clavicles (upper limit of normal: 4 cm above the sternal notch in a vertical plane). The venous column is elevated in heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular failure causes shortness of breath and fatigue, and right ventricular failure causes peripheral and abdominal fluid... read more Heart Failure (HF) , volume overload Volume Overload Volume overload generally refers to expansion of the extracellular fluid (ECF) volume. ECF volume expansion typically occurs in heart failure, kidney failure, nephrotic syndrome, and cirrhosis... read more , cardiac tamponade Cardiac Tamponade Cardiac tamponade is accumulation of blood in the pericardial sac of sufficient volume and pressure to impair cardiac filling. Patients typically have hypotension, muffled heart tones, and distended... read more , constrictive pericarditis Pericarditis Pericarditis is inflammation of the pericardium, often with fluid accumulation. Pericarditis may be caused by many disorders (eg, infection, myocardial infarction, trauma, tumors, metabolic... read more Pericarditis , tricuspid stenosis Tricuspid Stenosis Tricuspid stenosis (TS) is narrowing of the tricuspid orifice that obstructs blood flow from the right atrium to the right ventricle. Almost all cases result from rheumatic fever. Symptoms include... read more , superior vena cava obstruction, or reduced compliance of the right ventricle. If such conditions are severe, the venous column can extend to jaw level, and its top can be detected only when the patient sits upright or stands. The venous column is low in hypovolemia Volume Depletion Volume depletion, or extracellular fluid (ECF) volume contraction, occurs as a result of loss of total body sodium. Causes include vomiting, excessive sweating, diarrhea, burns, diuretic use... read more .

Normally, the venous column can be briefly elevated by firm hand pressure on the abdomen (hepatojugular or abdominojugular reflux); the column falls back in a few seconds (maximum 3 respiratory cycles or 15 seconds) despite continued abdominal pressure (because a compliant RV increases its stroke volume via the Frank-Starling mechanism). However, the column remains elevated (> 3 cm) during abdominal pressure in disorders that cause a dilated and poorly compliant RV or in obstruction of RV filling by tricuspid stenosis Tricuspid Stenosis Tricuspid stenosis (TS) is narrowing of the tricuspid orifice that obstructs blood flow from the right atrium to the right ventricle. Almost all cases result from rheumatic fever. Symptoms include... read more or right atrial tumor.

Normal jugular vein waves

The a wave is caused by right atrial contraction (systole) and is followed by the x descent, which is caused by atrial relaxation. The c wave, an interruption of the x descent, is caused by the transmitted carotid pulse; it is seldom discerned clinically. The v wave is caused by right atrial filling during ventricular systole (tricuspid valve is closed). The y descent is caused by rapid filling of the right ventricle during ventricular diastole before atrial contraction.

Normal jugular vein waves

The a waves are increased in pulmonary hypertension and tricuspid valve stenosis. Giant a waves (Cannon waves) occur in atrioventricular dissociation when the atrium contracts while the tricuspid valve is closed. The a waves disappear in atrial fibrillation and are accentuated when RV compliance is poor (eg, in pulmonary hypertension or pulmonic stenosis). The v waves are very prominent in tricuspid regurgitation. The x descent is steep in cardiac tamponade. When RV compliance is poor, the y descent is very abrupt because the elevated column of venous blood rushes into the RV when the tricuspid valve opens, only to be stopped abruptly by the rigid RV wall (in restrictive myopathy) or the pericardium (in constrictive pericarditis).

Chest Inspection and Palpation

Chest contour and any visible cardiac impulses are inspected. The precordium is palpated for pulsations (determining apical impulse and thus cardiac situs) and thrills.

Inspection

Chest deformities may occur in a number of disorders.

Shield chest and pectus carinatum (a prominent birdlike sternum) may be associated with Marfan syndrome Marfan Syndrome Marfan syndrome consists of connective tissue anomalies resulting in ocular, skeletal, and cardiovascular abnormalities (eg, dilation of ascending aorta, which can lead to aortic dissection)... read more Marfan Syndrome (which may be accompanied by aortic root or mitral valve disease) or Noonan syndrome Primary hypogonadism Male hypogonadism is decreased production of testosterone, sperm, or both or, rarely, decreased response to testosterone, resulting in delayed puberty, reproductive insufficiency, or both. Diagnosis... read more (which may be accompanied by pulmonic stenosis Pulmonic Stenosis Pulmonic stenosis (PS) is narrowing of the pulmonary outflow tract causing obstruction of blood flow from the right ventricle to the pulmonary artery during systole. Most cases are congenital... read more , atrial septal defects Atrial Septal Defect (ASD) An atrial septal defect (ASD) is an opening in the interatrial septum, causing a left-to-right shunt and volume overload of the right atrium and right ventricle. Children are rarely symptomatic... read more , or hypertrophic cardiomyopathy Hypertrophic Cardiomyopathy Hypertrophic cardiomyopathy is a congenital or acquired disorder characterized by marked ventricular hypertrophy with diastolic dysfunction but without increased afterload (eg, due to valvular... read more Hypertrophic Cardiomyopathy ). Rarely, a localized upper chest bulge indicates aortic aneurysm Overview of Aortic Aneurysms Aneurysms are abnormal dilations of arteries caused by weakening of the arterial wall. Common causes include hypertension, atherosclerosis, infection, trauma, and hereditary or acquired connective... read more Overview of Aortic Aneurysms due to syphilis.

Palpation

The patient lays at approximately a 30 to 45 degree angle. Approaching the patient from the right side, the clinician systematically palpates the precordium.

The apical impulse in healthy individuals should be palpable between the 4th and 5th intercostal space just medial to the midclavicular line and cover an area < 2 to 3 cm in diameter.

A central precordial heave is a palpable lifting sensation under the sternum and anterior chest wall to the left of the sternum; it suggests severe right ventricular hypertrophy. Occasionally, in congenital disorders that cause severe RV hypertrophy, the precordium visibly bulges asymmetrically to the left of the sternum.

A sustained thrust at the apex (easily differentiated from the less focal, somewhat diffuse precordial heave of RV hypertrophy) suggests LV hypertrophy.

Abnormal focal systolic impulses in the precordium can sometimes be felt in patients with a dyskinetic ventricular aneurysm. An abnormal diffuse systolic impulse lifts the precordium in patients with severe mitral regurgitation. The lift occurs because the left atrium expands, causing anterior cardiac displacement. A diffuse and inferolaterally displaced apical impulse is found when the LV is dilated and hypertrophied (eg, in mitral regurgitation Mitral Regurgitation Mitral regurgitation (MR) is incompetency of the mitral valve causing flow from the left ventricle (LV) into the left atrium during ventricular systole. MR can be primary (common causes are... read more ).

Table
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A sharp impulse at the 2nd intercostal space to the left of the sternum may result from exaggerated pulmonic valve closure in pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension is increased pressure in the pulmonary circulation. It has many secondary causes; some cases are idiopathic. In pulmonary hypertension, pulmonary vessels become constricted... read more . A similar early systolic impulse at the cardiac apex may represent closure of a stenotic mitral valve Mitral Stenosis Mitral stenosis is narrowing of the mitral orifice that impedes blood flow from the left atrium to the left ventricle. The (almost) invariable cause is rheumatic fever. Common complications... read more ; opening of the stenotic valve sometimes can be felt at the beginning of diastole. These findings coincide with an augmented 1st heart sound and an opening snap of mitral stenosis, heard on auscultation.

Lung Examination

Percussion is the primary physical maneuver used to detect the presence and level of pleural effusion. Finding areas of dullness during percussion signifies underlying fluid or, less commonly, consolidation.

Palpation includes tactile fremitus (vibration of the chest wall felt while a patient is speaking); fremitus is decreased in pleural effusion and pneumothorax and increased in pulmonary consolidation (eg, lobar pneumonias).

The character and volume of breath sounds are useful in differentiating cardiac from pulmonary disorders. Adventitious sounds are abnormal sounds, such as crackles, rhonchi, wheezes, and stridor. Crackles (previously called rales) and wheezes are abnormal lung sounds that may occur in heart failure as well as non-cardiac diseases.

Abdominal and Extremity Examination

The abdomen and extremities are examined for signs of fluid overload, which may occur with heart failure as well as noncardiac disorders (eg, renal, hepatic, lymphatic).

Abdomen

In the abdomen, significant fluid overload manifests as ascites Ascites Ascites is free fluid in the peritoneal cavity. The most common cause is portal hypertension. Symptoms usually result from abdominal distention. Diagnosis is based on physical examination and... read more . Marked ascites causes visible abdominal distention, which is tense and nontender to palpation, with shifting dullness on abdominal percussion and a fluid wave. The liver may be distended and slightly tender, with a hepatojugular reflux present.

Extremities

In the extremities (primarily the legs), fluid overload is manifest as edema Edema Edema is swelling of soft tissues due to increased interstitial fluid. The fluid is predominantly water, but protein and cell-rich fluid can accumulate if there is infection or lymphatic obstruction... read more Edema , which is swelling of soft tissues due to increased interstitial fluid. Edema may be visible on inspection, but modest amounts of edema in very obese or muscular people may be difficult to recognize visually. Thus, extremities are palpated for presence and degree of pitting (visible and palpable depressions caused by pressure from the examiner’s fingers, which displaces the interstitial fluid). The area of edema is examined for extent, symmetry (ie, comparing both extremities), warmth, erythema, and tenderness. With significant fluid overload, edema may also be present over the sacrum, genitals, or both.

Tenderness, erythema, or both, particularly when unilateral, suggests an inflammatory cause (eg, cellulitis or thrombophlebitis). Nonpitting edema is more suggestive of lymphatic or vascular obstruction than fluid overload.

Point-of-Care Ultrasonography (POCUS)

Point-of-care ultrasonography (POCUS) is a complement to the physical examination that uses small, inexpensive, battery-operated ultrasound devices operated by the clinician at the bedside. Both 2-dimensional and color Doppler techniques can be used. It has been shown that a brief, focused ultrasound examination can improve detection of various cardiac anomalies and confirm findings from physical examination or sometimes make a diagnosis in the absence of physical findings. Common uses include identification of (1, 2 Point of care ultrasound references Complete examination of all systems is essential to detect peripheral and systemic effects of cardiac disorders and evidence of noncardiac disorders that might affect the heart. Examination... read more Point of care ultrasound references )

  • Left ventricular systolic dysfunction (with global or regional wall motion abnormality)

  • Left ventricular regional wall motion abnormality (with reduced or normal systolic function)

  • Elevated left heart filling pressures (enlarged left atrium)

  • Valve structure and function

  • Pulmonary edema (vertical B-lines in the lung fields)

  • Pleural effusion

  • Systemic venous congestion (dilated inferior vena cava)

  • Pericardial effusion and cardiac tamponade

Adequate training in doing brief ultrasound examinations is essential to ensure high image quality and accurate interpretation (2 Point of care ultrasound references Complete examination of all systems is essential to detect peripheral and systemic effects of cardiac disorders and evidence of noncardiac disorders that might affect the heart. Examination... read more Point of care ultrasound references ). Importantly, POCUS should be used to augment rather than replace the physical examination.

Point of care ultrasound references

  • 1. Kimura BJ: Point-of-care cardiac ultrasound techniques in the physical examination: better at the bedside. Heart 103:987–994, 2017. doi: 10.1136/heartjnl-2016-309915

  • 2. Spencer KT, Kimura BJ, Korcarz CE, et al: Focused Cardiac Ultrasound: Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 26:567–581, 2013. doi: 10.1016/j.echo.2013.04.001

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