Cardiovascular examination

The cardiovascular examination is an essential cardiological tool that comprises the assessment of vital signs and jugular venous pulse, chest inspection and palpation, and, most importantly, auscultation of the heart. For specific auscultatory findings in valvular heart disease, see “Auscultation in valvular defects.” For specific auscultatory findings of heart defects, see “Congenital heart defects.” Details regarding the specific signs and symptoms of cardiovascular disease can be found via the links provided below.

History ^[1]

• Dyspnea
• Chest pain (see “Cardiovascular causes of chest pain”)
• Palpitations: an unpleasant awareness of one's own heartbeat; can feel like a fluttering or pounding in the chest
• Syncope
• Hemoptysis
• Edema
• Fatigue
• Claudication

General examination ^[1]

Appearance

• Level of consciousness
• Syndromic features (e.g., in trisomy 21, trisomy 18; associated with congenital heart defects)
• Features of rheumatic fever: migrating polyarthritis, erythema marginatum, subcutaneous nodules
• Features of left-sided heart failure
• Features of right-sided heart failure

Skin and mucous membranes

• Color changes
  • Central cyanosis (see features of “Cyanotic congenital heart defects” and “Congestive heart failure”)
  • Pallor (anemia)
  • Plethora (polycythemia)
• Xanthomas (dyslipidemia)
• Dehydration
• Temperature

Hands

• Perfusion
  • Temperature
  • Capillary refill time
  • Peripheral cyanosis
• Palms: Osler nodes, Janeway lesions (see “Clinical features of infective endocarditis”)
• Nails: clubbing, splinter hemorrhages

Face

• General
  • Malar flush
  • Swollen face
• Eyes
  • Xanthelasmas, arcus lipoides corneae (dyslipidemia)
  • Hypertensive retinopathy (ophthalmologic examination)
• Mouth
  • Poor dental health
  • High arched palate (Marfan syndrome)

Neck

• Carotid pulse
• Jugular venous pressure (see “Clinical assessment of jugular venous pressure”)

Other

• Lung bases: pulmonary edema
• Lower limbs
  • Peripheral edema
  • Signs of venous insufficiency
• Signs of stroke

Approach ^[1]

1. The patient should sit for several minutes before blood pressure is measured.
2. Use the correct cuff size.
3. Ask the patient to rest the arm on a horizontal surface at the level of the heart.
4. Record the pressure in both arms and note any differences.
5. Determine the systolic and diastolic blood pressure value (e.g., auscultatory method using Korotkoff sounds over the brachial artery).
6. Repeat measurement.

24-hour ambulatory blood pressure measurement can be helpful in establishing the average and peak blood pressure values during daily activities.

Interpretation

• Korotkoff sounds
  • Definition: sounds heard when auscultating over the brachial artery during sphygmomanometry
  • Origin: turbulent blood flow through a brachial artery that is partially compressed by the inflated arm cuff of a sphygmomanometer
  • Interpretation: When deflating the cuff, the pressure at which Korotkoff sounds appear marks systolic BP, and the pressure at which Korotkoff sounds disappear marks diastolic BP.
• Normal blood pressure
  • Systolic blood pressure < 120 mm Hg and diastolic blood pressure < 80 mm Hg ^[1]
  • See also “Normal vital signs at rest” for all age groups.
  Hypotension
  • Systolic blood pressure < 90 mm Hg ^[2]
  • See “Orthostatic syncope.”
• Hypertension
  • Systolic blood pressure ≥ 130 mm Hg and/or a diastolic blood pressure ≥ 80 mm Hg ^[3]
  • See “Diagnosis of hypertension.”

Sources of errors in blood pressure measurement ^[4]

• Incorrect positioning
• White coat hypertension
• Mönckeberg arteriosclerosis ^[5]
• Incorrect cuff size
• Auscultatory gap
  • Korotkoff sounds between systolic and diastolic blood pressures sometimes diminish or disappear, presumably due to increased arterial stiffness in hypertensive patients.
  • When the cuff is insufficiently pumped (i.e., below systolic blood pressure), the first appearance of Korotkoff sounds is misinterpreted as systolic blood pressure (a falsely low reading).
  • The falsely low reading can be prevented by simultaneously palpating the radial pulse on the arm in which blood pressure is measured.

Jugular venous pressure (JVP) can be used to estimate central venous pressure (CVP) and provides information about fluid status and cardiac function.

Approach ^[1]

• The patient should be in the supine position, torso elevated to 45°, with the head extended backward and turned to the left.
• Identify the venous pulsation of the internal jugular vein and evaluate the following:
  • The height of the internal jugular venous filling pressure, by measuring it from the sternal angle
  • Estimation of the CVP, obtained by adding 5 cm to the JVP height
  • The character of the JVP, by assessing JVP waves
• Hepatojugular reflux should be tested if JVP cannot be assessed properly.

Interpretation ^[1]

Height

• Elevated JVP: > 4 cm filling level of the internal jugular vein above the sternal notch
• Signs of an elevated JVP
  • Jugular venous distention
  • Kussmaul sign: distention of the jugular veins during inspiration due to the negative intrathoracic pressure that attempts to pull blood into the right heart, which is restricted by noncompliant pericardium or myocardium (e.g., constrictive pericarditis, restrictive cardiomyopathy, right atrial tumors, ventricular tumors, right HF, massive PE) ^[6]
  • Hepatojugular reflux
• Causes of elevated JVP
  • Right heart failure
  • Fluid overload
  • Tricuspid valve dysfunction
  • Pericardial effusion
  • Constrictive pericarditis
  • Cardiac tamponade
  • SVC syndrome
  • Pulmonary hypertension

Character

A normal JVP waveform consists of three waves (a, c, v) and two descents (x, y).

A pulse wave is produced by ventricular contraction during systole.

Approach ^[1]

• Three-finger method: palpation with tips of the 2^nd, 3^rd, and 4^th fingers
• Palpate the common carotid artery, radial artery, abdominal aorta, femoral artery, popliteal artery, tibialis posterior artery, and dorsalis pedis artery.
• The carotid artery pulse should never be palpated at the same time bilaterally. ^[8]
  • Risk of compression of vessels → cerebral hypoperfusion → syncope
  • Risk of hyperstimulation of the carotid sinus reflex → bradycardia/low blood pressure → cerebral hypoperfusion → syncope

The thumb of the examiner should never be used to take the pulse because its own strong pulse might be mistaken for the patient's pulse.

Palpation ^[1]

The pulse should be assessed for rate, rhythm, character, volume, the speed of upstroke, and delay.

Auscultation ^[1]

• Auscultate over the carotid arteries, abdominal aorta, renal arteries, and femoral arteries to detect bruits, which are vascular murmurs caused by turbulent, nonlaminar blood flow in a vessel.
• Causes of bruits
  • AV fistulae
  • Arteriovenous malformations
  • Aneurysms
  • Vascular stenosis
  • Hyperdynamic circulation
    • E.g., pregnancy, fever, anemia, hyperthyroidism
    • May occur physiologically in adolescents

Approach ^[1]

The patient is asked to undress from the waist up and the physician evaluates for the following:

• Scars (e.g., heart surgery, pacemakers)
• Chest deformities (e.g., pectus carinatum, pectus excavatum)
• Visible apex beat
• Distended veins (e.g., in SVC obstruction)
• De Musset sign: head bobbing in time with the pulse (seen in aortic regurgitation)

Apex beat ^[1]

The apex beat (apex impulse) is the outermost and lowermost palpable cardiac impulse on the chest wall.

Palpation of the apex beat ^[1]

• Approach
  • Performed in the supine position with the torso elevated to 45°
  • The examiner places a flat hand on the cardiac apex to locate the apex beat, and further localizes and assesses the beat by palpating with 2–3 fingers.
  • If the apex beat is not initially palpable, the patient should be positioned on the left lateral side and the cardiac apex palpated during expiration.
• Normal findings
  • Position: 5^th left intercostal space in the midclavicular line
  • Character: a brief (early systolic) impulse that is felt over an area of 2–3 cm²

Other impulses ^[1]

• Parasternal heave
  • A heaving motion felt over the left parasternal area while palpating with the heel of the right hand
  • Suggests right ventricular hypertrophy
• Thrills: a palpable heart murmur, usually over the region where the murmur is heard best
• Palpable heart sounds
  • Palpate over valve areas (see “Auscultatory locations”).
  • A palpable P2 suggests pulmonary hypertension.
• Epigastric pulsations
  • Visible or palpable pulsations over the epigastric region of the abdomen
  • Associated with right ventricular hypertrophy or an abdominal aortic aneurysm

Although cardiac percussion can provide some information about the size and shape of the heart, it is very unreliable and dependent on the examiner and is thus of limited clinical use.

Approach ^[1]

• The patient should be in a supine position with the torso elevated to 45°.
• Ask the patient to refrain from speaking while the heart sounds are being assessed.
• The radial pulse should be palpated while auscultation is performed.
• If heart sounds are weakly audible, ask the patient to hold their breath after exhaling.
• Assess the following:
  • Location, timing, changes in intensity, and splitting of heart sounds
  • Abnormal heart sounds
  • Murmurs

Auscultatory locations ^[1]

"All Physicians Earn Too Much" (Aortic, Pulmonary, Erb point, Tricuspid, Mitral)

Normal heart sounds ^[1]

• The first (S1) and second (S2) heart sounds are physiological sounds heard in all healthy individuals.
• The third (S3) and fourth (S4) heart sounds may be physiological (particularly in young adults, pregnant women, and the elderly) or pathological.

Extra heart sounds ^[1]

Gallops that originate from the left side of the heart (the most common) become softer with inspiration, while those that originate from the right side become louder.

Changes in intensity ^[9]

Increased or decreased intensity (loudness) of the heart sounds may indicate certain pathologies.

S1 intensity

• Loud S1
  • Mitral stenosis
  • Tachycardia
  • Hyperdynamic states (e.g., left-to-right shunts )
  • Short PR interval (e.g., AVRT)
• Soft S1
  • Severe mitral stenosis
  • Conditions that impair the transmission of heart sounds to the chest wall: COPD, pneumothorax, pericardial effusion, obesity
  • LBBB
  • Prolonged PR interval (e.g., first-degree heart blocks)
• Variable intensity
  • Atrial fibrillation
  • AV dissociation
  • Auscultatory alternans: severe LV failure, large pericardial effusion

S2 intensity

• Loud A2: arterial hypertension, coarctation of the aorta
• Loud P2: pulmonary hypertension , atrial septal defects ^[10]

Splitting of heart sounds ^[1]

If the aortic and pulmonary valves do not close simultaneously, an apparent splitting of S2 can be heard upon auscultation.

Additional sounds ^[1]

• Clicks are crisp sounds produced by the movement of abnormal valves.
• Other sounds may also be heard, such as an opening snap, pericardial friction rub, pericardial knock.

The presence of an aortic ejection click can be used to differentiate a pathological systolic murmur of aortic stenosis from a flow murmur. When the click is present, the murmur is pathological.

The absence of a click in patients with prosthetic valves may indicate valve failure.

Overview ^[1]

• Murmurs are blowing or whooshing sounds that occur as a result of turbulent blood flow.
• They are described according to the location, radiation, timing, intensity, configuration, frequency, and response to dynamic maneuvers.
• For specific auscultatory findings in valvular heart disease, see “Auscultation in valvular defects.”
• For specific auscultatory findings of heart defects, see “Congenital heart defects.”

Functional and pathological murmurs

Murmurs may be functional or pathological.

Location and radiation ^[1]

• Location: see “Auscultatory locations.”
• Radiation
  • Aortic stenosis: a systolic murmur radiates to carotid arteries
  • Mitral regurgitation: a systolic murmur radiates to the left axilla (in the left lateral recumbent position)
  • Pulmonary stenosis: a systolic murmur radiates to the interscapular region

Timing ^[1]

Diastolic murmurs are almost always pathological.

Diastolic murmurs may require certain maneuvers to make them more apparent, e.g., letting the patient sit and lean forward to intensify the murmur of aortic regurgitation.

Intensity ^[1]

The intensity refers to the loudness of the murmur on auscultation (grades I–VI).

While most grade III and above murmurs are pathological, the intensity of a murmur does not always correlate to the severity of the underlying lesion. For example, a larger VSD produces a softer murmur than a small VSD, and a murmur of severe aortic stenosis may disappear if a patient develops left heart failure.

All diastolic murmurs and any grade II and above systolic murmurs require further echocardiographic evaluation.

Configuration ^[1]

The configuration describes the change in intensity (loudness) of a murmur, which is determined by the pressure gradient driving the turbulent flow.

• Types
  • Uniform: unchanging intensity
  • Crescendo: increasing intensity
  • Decrescendo: decreasing intensity
  • Crescendo-decrescendo: initial increase followed by a decrease in intensity

Frequency (pitch) ^[1]

The frequency of a murmur is determined by the velocity of turbulent flow, which is in turn affected by the pressure gradient.

• High pitch: high-pressure gradient and high-velocity flow (e.g., VSD)
• Low pitch: low-pressure gradient and low-velocity flow (e.g., mitral stenosis)

Maneuvers ^[1]

Certain maneuvers may be performed to elicit a change in the intensity of a murmur.

Exceptions to maneuvers

In the following conditions, maneuvers that increase preload decrease the intensity of the murmur and vice versa.

• HOCM
• MVP

Maneuvers that decrease LV preload (e.g., inspiration, Valsalva maneuver) usually decrease the intensity of murmurs arising from the left side of the heart, except in HOCM and MVP, in which a decrease in LV preload increases the intensity of the murmur.

Audio clip examples of murmurs

Imaging ^[13]

• Electrocardiography
• Cardiac stress test
• Chest x-ray
• Echocardiography
• Cardiac MRI/CT
• Cardiac scintigraphy (especially in ischemic cardiac disease)

Chest x-ray (heart)

The heart shadow can be viewed on a chest x-ray.

• Heart contour in the lateral view
  • Anterior border: right ventricle
  • Inferior border: left ventricle
  • Posterosuperior border: left atrium
• Heart contour in the posteroanterior (PA) view
  • Right border (from caudal to cranial): right atrium, superior vena cava
  • Left border (from caudal to cranial): left ventricle, left atrial appendage, pulmonary trunk, aortic knuckle
  • Inferior border: right ventricle
• Cardiothoracic ratio (heart size)
  • The cardiac diameter is divided by the thoracic diameter on the same horizontal level in a PA view.
  • The normal cardiothoracic ratio is between 0.42 and 0.5.
  • Cardiomegaly: an enlarged heart (cardiothoracic ratio > 0.5) due to a variety of conditions, e.g., arterial hypertension, CAD, athletic heart syndrome
• Assess the lung fields, e.g., for signs of pulmonary edema.

Echocardiography

• Transthoracic echocardiography (TTE)
  • A noninvasive ultrasonographic examination of the heart in which a transducer is placed on the anterior chest wall and the epigastrium
  • Recommended for initial evaluation of pathological murmurs (e.g., diastolic murmur, late systolic murmur, all symptomatic murmurs) ^[14]
  • Used to assess valvular function by determining the following:
    • Average pressure gradient
    • Valve area: decreased in valvular stenosis (e.g., a small valve area with a high-pressure gradient indicates severe stenosis)
    • Amount of reflux via a color duplex scan: increased in valvular insufficiency
  • Used to assess myocardial contractility (e.g., decreased contractility in heart failure, cardiac wall motion abnormalities in myocardial infarction, right ventricular hypokinesia in pulmonary embolism)
  • Used to evaluate for other pathologies (e.g., septal defects, aneurysms, thrombi, vegetations, pericardial effusions)
• Transesophageal echocardiography (TEE)
  • An ultrasonographic examination of the heart, coronary vessels, and thoracic aorta performed by endoscopically inserting a transducer through the esophagus
  • Used to identify atrial septal defects and infective endocarditis, as well as to differentiate between thoracic aortic diseases (e.g., aneurysm, dissection)
  • Also used during cardiac surgery or catheterization

Invasive tests ^[13]

• Cardiac catheterization
  • Coronary angiography and, possibly, PCI
  • Direct measurement of the ventricular and aortic pressures to determine the degree of valvular stenosis
  • Cardiac ventriculography to directly visualize and quantify the reflux of the contrast material in valvular insufficiencies
  • Right heart catheterization
• Electrophysiological study
  • To assess cardiac arrhythmias
  • The cardiac arrhythmia is often treated during the test itself (e.g., by ablation).
• Myocardial biopsy
  • If there is suspicion for cardiomyopathies, myocarditis, or systemic illnesses with cardiac involvement (e.g., sarcoidosis, amyloidosis, hemochromatosis)
  • Follow-up after heart transplantation (to rule out the possibility of organ rejection)