• Clinical science

Cardiovascular examination


Cardiovascular examination is a central tool for assessing the cardiovascular system. Examination includes 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 in the links provided below.

History and general examination


General examination

  • Malar flush (red cheeks, seen in patients with mitral stenosis)
  • Swollen face


Blood pressure


  1. The patient should be sitting for several minutes before measuring blood pressure.
  2. Use correct cuff size.
  3. The patient should be asked to rest his/her straight arm horizontally on a surface at heart level.
  4. Record the pressure in both arms (and legs) and note any differences.
  5. Determine the systolic and diastolic blood pressure value.
  6. Repeat measurement.
  7. Ambulatory blood pressure measurement (24 hours) may be helpful in establishing the average and peak blood pressure values during daily activities.

See table under “Definition” in the article on hypertension for details regarding normal and pathologic blood pressure values.


Central venous pressure

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



A pulse wave is produced by ventricular contraction during systole.


The thumb of the examiner should never be used to take the pulse as it has its own strong pulse, which might be mistaken for the patient's pulse!


Characteristics of pulse

Description Possible causes
  • Regular
  • Physiological
  • Regularly irregular
  • Irregularly irregular
  • Pulsus bigeminus: regularly irregular; two heartbeats occur in rapid succession (usually a high volume pulse followed by a low volume pulse) followed by a long gap

Pulse volume (amplitude)

  • Low blood pressure
Pulse wave tension
  • Low-tension pulse: The vessel wall is either soft or not palpable between beats and is easily compressible.
  • Low blood pressure
  • Systemic vasodilatation (e.g., due to sepsis)
Speed of pulse upstroke (wave contour)



Chest inspection


The patient is initially requested to remove their upper body attire to identify:

Chest palpation

Apex impulse

  • The apex impulse (apex beat) is the outermost and lowermost cardiac impulse on the chest wall that is definitely palpable.
  • The examiner places their flat hand on the cardiac apex to locate the apex beat; it is further localized and assessed by palpating with 2–3 fingers.
  • If the apex beat is not initially palpable, the patient should be positioned on his/her left lateral side and the cardiac apex should be palpated during expiration.

No conclusion can be drawn from the location of the apex beat in the presence of spinal or chest wall deformities or a tracheal deviation (mediastinal shift)!

Other impulses


Chest percussion

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.

Chest auscultation


  • Performed in the supine position with slight elevation of the torso
  • Politely ask the patient to refrain from speaking while the heart sounds are being assessed.
  • The pulse should be simultaneously palpated during auscultation (mainly the radial artery).
  • If heart sounds are weakly audible, request that the patient holds their breath for a moment after expiration (respiratory rest position).
  • Assess the following:

Heart sounds

Location and timing

  • The first (S1) and second (S2) heart sounds are physiological sounds that are 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 indicate an underlying pathology.
Heart sound Origin Timing Occurrence
Primary heart sounds
1st heart sound (S1)
  • Onset of systole
  • Heard just before the carotid pulsation is felt
  • Always
2nd heart sound (S2)
  • Transition from systole to diastole
  • Heard immediately after the carotid pulsation
Extra heart sounds (gallops)
3rd heart sound (S3)
4th heart sound (S4)
  • Immediately before S1
  • Atrial gallop: Ten-nes-see pattern (S4-S1-S2)

Gallops more commonly arise from the left side of the heart. Gallops that originate from the left side of the heart become softer with inspiration while those that originate from the right side become louder!

Splitting of heart sounds

  • If the aortic and pulmonary valves do not close simultaneously, an apparent splitting of S2 can be heard upon auscultation.
Description Cause
Splitting of S2 Physiological split
  • The split is especially pronounced among young individuals.

Wide split

  • An exaggerated physiological split, i.e., more pronounced during inspiration (A2 precedes P2).

Fixed split

  • A split in S2 that does not change with respiration, i.e., the split is also audible during expiration.

Paradoxical split (reversed split)

  • The split in S2 is audible during expiration but not inspiration.
Absent split


Abnormal heart sounds

Ejection sounds (Clicks)

Clicks are crisp sounds produced by the movement of abnormal valves.

Mechanism Timing Technique of auscultation
Aortic ejection click
  • Early-systolic sound (immediately after S1)
  • Best heard with the diaphragm of a stethoscope at the aortic region with the patient seated and leaning forward
Mitral valve opening snap
  • Early-diastolic sound (immediately after S2)
  • Best heard with the bell of a stethoscope at the mitral region with the patient in a left lateral position
Mitral valve prolapse click
  • Midsystolic sound
  • Best heard with the diaphragm of a stethoscope at the mitral region with the patient in left lateral position
Mechanical valve clicks
  • Appropriate (see S1 and S2 above)
  • With the diaphragm of a stethoscope

The presence of an aortic ejection click can be used to differentiate a pathological systolic murmur of aortic stenosis from a flow murmur!

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

Other abnormal heart sounds

Heart murmurs

Sounds produced by the turbulent flow of blood within the heart; are known as murmurs. They are described based on the location and radiation of the murmur, timing, intensity, configuration, frequency, and response to maneuvers. Murmurs can be classified as either functional or pathological.

Functional murmur (physiological or innocent)

Pathologic murmur
  • Non-cardiac or peripheral cause: due to increased blood flow across normal aortic and/or pulmonary valves (ejection murmur)
  • Most commonly occurs in infants and children but also in individuals without cardiac conditions (particularly thin or pregnant individuals) due to e.g., hyperdynamic circulation
  • Cardiac conditions and structural abnormalities (e.g., valvular defects) must be ruled out.
  • Caused by structural defects (valvular disease or heart defects)


  • Soft (< 3/6 without a thrill)
  • Typically > 3/6
  • Thrill may be present
Position change
  • Position-dependent; murmur varies in intensity or disappears

Auscultatory locations

Location Pathology
Erb's point (cardiology)
Aortic area
Pulmonic area
Mitral area
Tricuspid area
Gibson's point
  • Left infraclavicular region

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


Murmur Timing Occurrence
Systolic murmurs
  • During ventricular contraction (i.e. occurs with or after S1 and before S2)
  • May be classified as early-systolic, mid-systolic, late-systolic, and holosystolic according to the onset and termination of the murmur
Diastolic murmurs
  • During ventricular relaxation (i.e., occurs with or after S2 and before S1)
  • May be classified as: early-diastolic, mid-diastolic, late-diastolic, or holo-diastolic according to the onset and termination of the murmur
  • Do not occur physiologically
  • Next best step in management: transthoracic echocardiogram
Continuous murmurs

A mid-systolic murmur in an asymptomatic individual is most likely physiological! Unlike systolic murmurs, diastolic murmurs are almost always pathological!

Diastolic murmurs may require that certain maneuvers be performed to make them more apparent.


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

Levine grading scale Loudness of the murmur
Grade I The murmur is heard only upon listening carefully for some time.
Grade II The murmur is faint but becomes immediately audible when the stethoscope is placed on the chest.
Grade III A readily audible loud murmur without a thrill.
Grade IV A loud murmur with a thrill.
Grade V A loud murmur with a thrill. The murmur is audible with just the rim of the stethoscope touching the chest.
Grade VI A loud murmur with a thrill. The murmur is audible with the stethoscope hovering above the chest.

While most murmurs of grade III and above 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 systolic murmurs of grade II and above require further echocardiographic evaluation!


The configuration of a murmur describes the change in intensity of the murmur.

  • Uniform: unchanging intensity
  • Crescendo: increasing intensity
  • Decrescendo: decreasing intensity
  • Crescendo-decrescendo: initial increase, followed by decrease in intensity (rhombus-shaped)


A murmur may be auscultated at a site that does not lie directly over the heart.

Response to maneuvers

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

Maneuver Effect on cardiac parameters Effect on murmurs


Valsalva maneuver/standing

  • ↓ Intensity of murmurs arising from the left side of the heart (see “Exception” below)
  • MVP: click occurs earlier

Squatting/lying down quickly/raising the legs

  • ↑ Intensity of all murmurs (see “Exception” below)
  • Tetralogy of Fallot: severity of "Tet spells" and the associated murmurs decrease with squatting.
  • MVP: click occurs later

Hand grip

Sitting leaning forward

  • No effect

Lying down in the left lateral position

  • No effect




  • Echocardiography: done as transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE) based on the indication
    • TTE recommended for evaluation of pathological murmurs (e.g., diastolic murmur, late systolic murmur, all symptomatic murmurs, etc)
    • Assess valvular function: allows one to classify the defect (mild, moderate, or severe)
      • Determine the average pressure gradient
      • Determine the valve area: decreased in case of valvular stenosis
      • Determine the amount of reflux via a color duplex scan: increased in the case of valvular insufficiency
    • Assess myocardial contractility
    • Detect and evaluate other pathologies (septal defects, aneurysms, thrombi, vegetations, etc.)
  • Cardiac MRI/CT
  • Cardiac scintigraphy (especially in the case of ischemic cardiac disease)

Invasive tests