• Clinical science

Cardiovascular examination

Abstract

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

History

General examination

Appearance
Hands
Face
  • Malar flush (red cheeks, seen in patients with mitral stenosis)
  • Swollen face
Eyes
Mouth
Neck
Other


References:[1][2]

Central venous pressure

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

Approach

Blood pressure

Approach

  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 learning card on hypertension for details regarding normal and pathologic blood pressure values.

Possible sources of errors in blood pressure measurement

  • Mönckeberg arteriosclerosis
  • Use of blood pressure cuffs that are too narrow or wide
  • Auscultatory gap Particularly in hypertensive patients, Korotkoff sounds between the systolic and diastolic blood pressure are diminished over a certain range of mm Hg or are absent. This is presumably due to carotid atherosclerosis and increased arterial stiffness in hypertensive patients. This can be clinically relevant when the cuff is insufficiently pumped (i.e., below the systolic blood pressure) and the first appearance of Korotkoff sounds are misinterpreted as systolic blood pressure (falsely low reading). This can be prevented by simultaneously palpating the radial pulse on the arm in which blood pressure is measured.

References:[3][4]

Pulses

A pulse wave is produced by ventricular contraction during systole.

Approach

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!

Palpation

Characteristics of pulse

Description Possible causes
Rate
  • Number of beats per minute
  • < 60 bpmbradycardia
  • > 100 bpmtachycardia
Rhythm
  • Regular
  • Physiological with minor changes during inspiration and expiration
  • Regularly irregular
  • Irregularly irregular
  • Pulsus bigeminus: two heartbeats occur in rapid succession (usually a high volume pulse followed by a low volume pulse) followed by a long gap (therefore regularly irregular)

Pulse volume (amplitude)

  • Low blood pressure
  • Pulsus paradoxus: pathological decrease in the pulse wave amplitude and systolic blood pressure of > 10 mm Hg during inspiration
  • HOCM
  • AV dissociation
  • Intermittent positive pressure ventilation (IPPV)
Pulse wave tension
  • Low blood pressure
  • Systemic vasodilatation (e.g., sepsis)
Speed of pulse upstroke (wave contour)
Delay
  • Radiofemoral delay

Auscultation

Blood vessel

Site of auscultation Distinctive characteristics of vascular murmur
Common carotid artery
Subclavian artery
  • Above and below the clavicle, approximately in its middle third
Brachial artery
Abdominal aorta
  • Upper middle abdomen, above the umbilicus
  • Vascular stenosis
    Aortic aneurysm
Renal artery
  • On both sides lateral to the auscultation site of the aorta; at the epigastrium, periumbilical, and in the flanks
Common iliac artery
  • Left/right lower quadrant of the abdomen
  • Vascular stenosis of the vessels
Femoral artery
  • Below the inguinal ligament
  • Subsequently, palpate caudally towards the femoral triangle.
  • Stenosis of the pelvic or the lower extremity vessels (systolic valvular murmur)
  • Arteriovenous fistula after puncture of the femoral artery (systolic-diastolic valvular murmur)
Popliteal artery
  • Knee pit


References:[5][6]

Chest inspection

Approach

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.
Position
  • Normal: 5th left intercostal space in the midclavicular line
  • Abnormal
    • Lateral and downward displacement → left ventricular hypertrophy
    • Lateral displacement → right ventricular hypertrophy, right tension pneumothorax, large pleural effusion, chest wall deformities
    • Displacement to the right hemithorax → dextrocardia
Quality

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


References:[7]

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

Approach

  • 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 S1 is heard 0.02—0.04 seconds after the onset of the QRS-complex.
  • Heard just before the carotid pulsation is felt
  • Always
  • See “Changes in intensity” and “Splitting of heart sounds” below for changes in S1.
2nd heart sound (S2)
  • Transition from systole to diastole
  • Heard immediately after the carotid pulsation
  • S2 coincides with the end of the T-wave on an ECG
Extra heart sounds (gallops)
3rd heart sound (S3)
  • Ventricular filling sound
    • Rapid ventricular filling
    • Sudden deceleration of blood when the ventricle reaches its elastic limit.
  • Best heard with the bell of the stethoscope at the mitral region/cardiac apex with the patient in a left lateral position
4th heart sound (S4)
  • Ventricular filling sound: late diastolic contraction of the atria (“atrial kick”) against a high ventricular pressure
  • Best heard with the bell of the stethoscope

  • Quadruple rhythm: S3 and S4 are both present and can be distinguished from one another.
  • Summation gallop: S3 and S4 are both present but indistinguishable.

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!

Changes in intensity

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

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 S1
  • Conduction disorders
  • Hemodynamic 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

References:[8][9][10]

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
  • 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)

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
Cause
  • 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)

Intensity

  • Soft (< 3/6 without a thrill)
  • Typically > 3/6
  • Thrill may be present
Timing
  • Most commonly mid-systolic or continuous murmur
  • Systolic, diastolic, or continuous
Position change
  • Position-dependent; murmur varies in intensity or disappears
  • Cervical venous hum: common benign auscultation finding in children
    • Caused by turbulent flow in internal jugular veins
    • Continuous murmur best heard at the infraclavicular and supraclavicular regions; more common on the right side
    • Becomes softer or disappears with flexion of the head, compression of the jugular vein, or in supine position
  • Still murmur

Auscultatory locations

Region Site at which a murmur is heard best Pathology
Erb's point (cardiology)
  • 3rd left parasternal intercostal space
Aortic region
  • 2nd right parasternal intercostal space
Pulmonary region
  • 2nd left parasternal intercostal space
Mitral region
Tricuspid region
  • 4th left parasternal intercostal space
  • Tricuspid stenosis
  • Tricuspid regurgitation
Gibson's point
  • Left infraclavicular region
  • Continuous murmur of a PDA is heard best at this point.

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

Timing

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
Continuous murmurs
  • During systole and diastole
  • PDA
  • Arteriovenous fistulas

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 certain maneuvers to accentuate them, while systolic murmurs usually radiate!

Intensity

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!

Configuration

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)

Radiation

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

Frequency (pitch)

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

  • High-pressure gradient: high pitch (e.g., VSD)
  • Low-pressure gradient: low pitch (e.g., mitral stenosis)
  • Mixture of high-pressure and low-pressure gradient: harsh murmur (high and low frequency; e.g. aortic stenosis)

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

Inspiration

Valsalva maneuver/standing

  • ↓ Intensity of murmurs arising from the left side of the heart (↑ intensity during the first phase) (see “Exception” below)
  • ↑ Intensity of murmurs arising from the right side of the heart
  • MVP: click occurs earlier

Squatting/lying down quickly/raising the legs

  • ↑ Intensity of all murmurs (see “Exception” below)
  • Tetralogy of Fallot: The 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

References:[11][12]

Diagnostics

Imaging

  • Echocardiography: done as transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE) based on the indication
    • Assess valvular function: allows one to classify the defect (mild, moderate, or severe)
      • Determine the average pressure gradient
        • Physiological: almost zero
        • Pathological: in the case of stenosis or in patients who have undergone valve replacement
      • 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, etc.)
  • Cardiac MRI/CT
  • Cardiac scintigraphy (especially in the case of ischemic cardiac disease)

Invasive tests