Cardiovascular Examination

Examination of the cardiovascular system (CVS) is a critical component of a thorough physical examination. As with all components of a complete physical examination, the CVS examination consists of inspection, palpation, and auscultation. The evaluation of the CVS focuses on the heart, but also includes an assessment of the arterial system throughout the body. A number of cardiovascular conditions can be diagnosed with a physical examination, including valvular heart disease, peripheral artery disease, and arrhythmia.

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Introduction

  • Equipment needed:
    • Stethoscope
    • Ruler (to measure jugular venous distention (JVD))
  • Positioning:
    • Ask the individual to lay at 30–45 degrees.
    • Expose the individual’s chest while maintaining modesty.
  • Environment:
    • Ensure good lighting, privacy, and hygiene. 
    • Drape individuals with a sterile gown, towel, or sheet.
  • Initial steps:
    • Introduce yourself.
    • Explain the examination and why it is needed.
    • Review the heart rate and blood pressure vital signs.

Inspection

Inspection is the 1st part of the cardiovascular examination. Take note of pertinent positive and negative findings. Cardiovascular disease can be detected through a thorough inspection of the entire body.

General appearance

  • General appearance/distress level of the individual:
    • Pertinent positives:
      • Well or no acute distress
      • Comfortable, normal affect
    • Pertinent negatives:
      • In distress (mild, moderate, or severe)
      • Disheveled
  • Level of consciousness: 
    • Alert: normal response
    • Confused: disoriented to surroundings
    • Lethargic: drowsy (needs stimulation to initiate a response)
    • Obtunded: slowly responding (needs repeated stimulation to maintain attention)
    • Stuporous: minimal response to stimulation
    • Comatose/unresponsive: no response to stimulation

Chest

  • Look for visible pulsations and thoracotomy scars.
  • Chest deformities:
    • Pectus excavatum:
      • Sunken sternum and ribs
      • Symptom of several connective tissue diseases (e.g., Marfan syndrome)
    • Pectus carinatum:
      • “Pigeon chest”
      • Protrusion of the sternum and ribs
    • Signs of trauma:
      • Flail chest: from fractures along the chest wall
      • Crepitus: air in the subcutaneous tissue

Head

  • Eyes:
    • Conjunctival pallor:
      • Assess by gently pulling down the lower eyelid.
      • Suggests anemia
    • Corneal arcus:
      • Yellowish-gray ring surrounding the iris
      • Indicates hypercholesterolemia
    •  Xanthelasma:
      • Yellow, raised lesions around the eyes
      • Indicates hypercholesterolemia
  • Mouth:
    • Central cyanosis:
      • Bluish discoloration of the lips
      • Indicates low oxygen levels
    • High arched palate:
      • Suggestive of Marfan syndrome
      • Associated with ↑ risk of aortic aneurysm/dissection
    • Dental hygiene: important if considering sources of infective endocarditis

Neck

Evaluate for JVD:

  • Lay the individual supine at 30–45 degrees.
  • Locate the external jugular vein as it crosses the sternocleidomastoid muscle.
  • Identify the point of maximal JVD.
  • From the sternomanubrial joint, measure the height of JVD.
  • Normal height: 6–8 cm
  • Increased distension suggests hypervolemia.
Evaluation of jugular venous distension

Evaluation of jugular venous distension (JVD) with the individual supine at 30–45 degrees

Image by Lecturio. License: CC BY-NC-SA 4.0

Extremities

  • Evaluate the fingers and nails for abnormalities:
    • Clubbing of the fingers suggests chronic hypoxia.
    • Cyanosis of nails suggests hypoxia.
    • Splinter hemorrhages in the nails suggest septic emboli.
    • Osler nodes:
      • Tender, red nodules on finger pulps
      • Indicates infective endocarditis
    • Janeway lesions:
      • Nontender, maculopapular, erythematous pulp lesions of the palm
      • Indicates bacterial endocarditis
    • Capillary refill time:
      • Normal: < 2 seconds
      • If prolonged suggestive of hypovolemia
    • Tar stain:
      • From smoking
      • Indicates risk factors for cardiovascular disease
  • Cool peripheries may suggest poor cardiac output/hypovolemia.
  • Sweaty/clammy skin can be associated with acute coronary syndrome.
  • Peripheral edema is a sign of congestive heart failure.

Palpation

The cardiovascular examination includes palpation of the pulses and the chest wall (precordium).

Pulses

Note the rate, rhythm, strength, character, and compare with contralateral pulses.

  •  Radial pulse:
    • Palpate the pulse lateral to the flexor carpi radialis tendon.
    • Radio-radial delay: 
      • Bilateral radial pulses occurring at different times
      • Suggests subclavian stenosis or aortic dissection
    • Collapsing pulse (“water hammer pulse”):
      • Bounding pulse with subsequent collapse
      • Suggests severe aortic regurgitation
  • Brachial pulse:
    • Palpate the pulse medial to the humerus within the upper arm.
    • Measure pulse pressure: the difference between systolic and diastolic pressure
    • Narrow pulse pressure: suggests aortic stenosis
    • Wide pulse pressure: suggests aortic regurgitation
  • Carotid pulse:
    • Palpate pulse between the sternocleidomastoid and the trachea.
    • Slow rising indicates aortic stenosis.

Precordium

  • Place the right hand across the individual’s left chest so it covers the area over the heart:
    • Rest the heel of the right hand along the sternal border.
    • Lay the extended fingers below the left nipple.
  • Identify the point of maximum impulse (where the heart beats the hardest):
    • A normal functioning ventricle will generate an impulse 2–3 cm in size. 
    • Best felt in the midclavicular line at the 5th intercostal space
    • A regular, single, nonsustained tapping should be felt.
  • Check for thrills or heave/thrust:
    • A thrill is a vibratory sensation made by turbulent blood flow due to valvular abnormalities.
    • A heave or thrust is an impulse in the left, low parasternal area (by intercostal spaces 3 and 4) indicative of right ventricular hypertrophy.
Palpation of the precordium, with the heel of the hand over the sternal border and fingers below the left nipple

Palpation of the precordium: the heel of the hand over the sternal border with fingers below the left nipple

Image by Lecturio. License: CC BY-NC-SA 4.0

Auscultation

Auscultation is best performed on bare skin. Maintain the individual’s modesty while performing examination maneuvers on the chest.

Technique

  • Requires use of both the bell and the diaphragm of the stethoscope
  • The bell auscultates low-pitched sounds:
    • Bruits (nonlaminar flow associated with stenosis)
    • Some heart murmurs
  • The diaphragm is used for all other sounds.
  • There are 4 points of auscultation of the precordium.
  • Mnemonic: APT-M
    • A (aortic valve): right 2nd intercostal space
    • P (pulmonic valve): left 2nd intercostal space 
    • T (tricuspid valve): left 4th intercostal space
    • M (mitral valve): lateral aspect of the 5th intercostal space

Heart sounds

  • S1 (lub) is the 1st heart sound and marks the beginning of systole and the end of diastole:
    • Sound of the closure of the mitral and tricuspid valves
    • Loudest at the apex
    • Precedes the carotid pulse
  • S2 (dub) is the 2nd heart sound and marks the end of systole and the beginning of diastole:
    • Sound of the closure of the aortic and pulmonic valves
    • Loudest at the base
    • After the carotid pulse
  • Extra heart sounds:
    • S3 is the 3rd heart sound (ventricular gallop):
      • Occurs just after S2 when the mitral valve opens
      • Produced by a large amount of blood striking a compliant left ventricle (LV)
      • S3 is often heard in the setting of systolic heart failure.
    • S4 is the 4th heart sound (atrial gallop):
      • Occurs just before S1
      • Sound of the atria contracting to force blood into a noncompliant LV 
      • S4 is often heard in the setting of acute cardiovascular ischemia.
    • Rubs:
      • The sounds produced with inflammation of the parietal and visceral pericardium.
      • A creaky/scratchy noise
  • Systolic murmurs:
    • Midsystolic murmur:
      • ↑ Flow through a normal valve (physiologic or innocent murmur)
      • Aortic stenosis
      • Pulmonary stenosis
      • Hypertrophic cardiomyopathy
      • Atrial septal defect
    • Late systolic murmur:
      • Mitral regurgitation (MR)
      • Due to papillary muscle dysfunction
      • Mitral valve prolapse or infective endocarditis
    • Pansystolic murmur:
      • MR
      • Tricuspid regurgitation
      • Ventricular septal defect (VSD)
      • Aortopulmonary shunts
  • Diastolic murmurs:
    • Aortic regurgitation
    • Pulmonic regurgitation
    • Mitral stenosis
    • Tricuspid stenosis

Special Maneuvers

Ankle-brachial index

  • The ankle-brachial index is measured to screen for peripheral artery disease.
  • Measure systolic blood pressure in bilateral ankles and arms.
  • Divide each ankle pressure by the highest systolic pressure; the ratio determines the presence or absence of peripheral artery disease.
Table: Ankle-brachial index interpretation
Ankle-brachial index ratioInterpretation
> 1.4Vessel hardening
1.0–1.4Normal
0.9–1.0Acceptable
0.8–0.9Mild arterial disease
0.5–0.8Moderate arterial disease
< 0.5Severe arterial disease
Measuring the systolic pressure at the ankle to calculate the ankle brachial index

Measuring the systolic pressure at the ankle to calculate the ankle-brachial index

Image by Lecturio. License: CC BY-NC-SA 4.0

Clinical Relevance

  • Peripheral artery disease: obstruction of the arterial lumen resulting in decreased blood flow to the distal limbs, which can be a result of atherosclerosis or thrombosis. Individuals may be either asymptomatic or have progressive claudication, skin discoloration, ischemic ulcers, or gangrene. The diagnosis can be made by assessing the ankle-brachial index. Treatment includes lifestyle modifications and antiplatelet therapy.
  • Congestive heart failure: refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Congestive heart failure is often a result of chronic hypertension or ischemic heart disease. The diagnosis can be suggested by physical exam findings of peripheral edema, increased JVD, and crackles in the lungs. Treatment includes lifestyle modifications and antihypertensive medications (most commonly acetylcholinesterase inhibitors and beta blockers).
  • Acute coronary syndrome: refers to acute ischemic heart disease resulting in unstable angina or myocardial infarction. Individuals present with acute onset of chest pain not relieved by rest. The diagnosis can be made by obtaining an electrocardiogram and measuring serum levels of cardiac enzymes (e.g., troponin). Acute coronary syndrome is a medical emergency and rapid treatment should be geared towards revascularization of the occluded area. 
  • Pericarditis: refers to inflammation of the pericardium. Pericarditis is often an idiopathic condition but can develop after myocardial infarction. Individuals present with pleuritic chest pain and friction rub, which can be heard while auscultating the heart. The chest pain classically improves when the individual leans forward. Antiinflammatory medications can improve the severity of chest pain.
  • Cardiac tamponade: occurs when fluid accumulates around the heart, ultimately compressing the heart and reducing cardiac output. Individuals classically present with Beck triad: hypotension, muffled heart sounds, and increased JVD. Cardiac tamponade is a medical emergency and must be treated with pericardiocentesis or pericardiotomy to remove the accumulated fluid.

References

  1. Walker HK, Hall WD, Hurst JW. (1990). Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Butterworths.
  2. Mangione S, Nieman LZ. (1997). Cardiac auscultatory skills of internal medicine and family practice trainees: A comparison of diagnostic proficiency. JAMA. 278: 717–22.
  3. Silverman ME, Wooley CF. (2008). Samuel A. Levine and the History of Grading Systolic Murmurs. Am J Cardiol. 102 (8): p.1107–10.
  4. Mangione S, Nieman LZ, Gracely E, Kaye D. (1993). The teaching and practice of cardiac auscultation during internal medicine and cardiology training: nationwide survey. Ann Intern Med 119: 47–54.
  5. Nardone, Lucan LM, Palac DM. (1998). Physical examination: A revered skill under scrutiny. Southern Medical Journal 81: 770–73.

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