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 “ .” For specific auscultatory findings of heart defects, see “ .” Details regarding the specific signs and symptoms of cardiovascular disease can be found via the links provided below.
History and general examination
- (see “”)
- Palpitations: an unpleasant awareness of one's own heartbeat; can feel like a fluttering or pounding in the chest
General examination 
- Level of consciousness
- Syndromic features (e.g., in , ; associated with congenital heart defects)
- Features of erythema marginatum: migrating polyarthritis, , subcutaneous nodules
Skin and mucous membranes
- Color changes
- Malar flush
- Swollen face
- Poor dental health
- High arched palate ()
- The patient should sit for several minutes before blood pressure is measured.
- Use the correct cuff size.
- Ask the patient to rest the arm on a horizontal surface at the level of the heart.
- Record the pressure in both arms and note any differences.
- Determine the systolic and diastolic blood pressure value (e.g., auscultatory method using Korotkoff sounds over the brachial artery).
- Repeat measurement.
24-hour ambulatory blood pressure measurement can be helpful in establishing the average and peak blood pressure values during daily activities.
- 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 
- See also “Normal vital signs at rest” for all age groups.
- Systolic blood pressure < 90 mm Hg 
- See “ .”
Sources of errors in blood pressure measurement 
- Incorrect positioning
- Incorrect cuff size
- 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.
- 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:
- should be tested if JVP cannot be assessed properly.
- Elevated JVP: > 4 cm filling level of the internal jugular vein above the sternal notch
Signs of an elevated JVP
- 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) 
- Causes of elevated JVP
A normal JVP waveform consists of three waves (a, c, v) and two descents (x, y).
|JVP waves and abnormalities |
|a wave|| || |
|c wave|| |
|x descent|| |
- Three-finger method: palpation with tips of the 2nd, 3rd, and 4th 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. 
The pulse should be assessed for rate, rhythm, character, volume, the speed of upstroke, and delay.
|Palpation of the arterial pulse|
|Rate|| || |
|Rhythm|| || |
|Speed of pulse upstroke (wave contour)|
- 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
The patient is asked to undress from the waist up and the physician evaluates for the following:
Apex beat 
The apex beat (apex impulse) is the outermost and lowermost palpable cardiac impulse on the chest wall.
Palpation of the apex beat 
- 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
|Abnormalities of the apex beat |
|Position|| || |
| || |
Other impulses 
- A heaving motion felt over the left parasternal area while palpating with the heel of the right hand
- Thrills: a palpable heart murmur, usually over the region where the murmur is heard best
- Palpable heart sounds
- Visible or palpable pulsations over the epigastric region of the abdomen
- Associated with or an
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.
- 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:
Auscultatory locations 
|Heart sound auscultation sites|
|Name of area||Location||Pathology|
|Erb point (cardiology)|| |
|Aortic area|| |
|Pulmonic area|| |
|Tricuspid area|| |
"All Physicians Earn Too Much" (Aortic, Pulmonary, Erb point, Tricuspid, Mitral)
Normal heart sounds 
- 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.
|Normal heart sounds|
|First heart sound (S1)|| || |
|Second heart sound (S2)|
Extra heart sounds 
|Extra heart sounds (gallops)|
|Third heart sound (S3)|
|Fourth heart sound (S4)|
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 
Increased or decreased intensity (loudness) of the heart sounds may indicate certain pathologies.
- Loud S1
- Soft S1
- Variable intensity
- Loud A2: arterial hypertension, coarctation of the aorta
- Loud P2: pulmonary hypertension , atrial septal defects 
Splitting of heart sounds 
|Splitting of heart sounds|
|Type of split||Description||Causes|
|Split S1|| |
|Physiological split|| || |
Paradoxical split (reversed split)
Additional sounds 
- 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.
|Additional sounds on cardiac auscultation|
|Aortic ejection click|
|Mitral valve prolapse click|| |
|Mitral valve opening snap|
|Mechanical valve clicks|
|Pericardial friction rub|
|Pericardial knock|| |
The absence of a click in patients with prosthetic valves may indicate valve failure.
- 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 “ .”
- For specific auscultatory findings of heart defects, see “ .”
Functional and pathological murmurs
Murmurs may be functional or pathological.
|Difference between functional and pathological murmurs|
Functional heart murmur (physiological or innocent)
| || |
|Position change|| || |
Location and radiation 
- Location: see “ .”
|Timing of heart murmurs |
|Systolic murmur|| |
|Diastolic murmur|| |
|Continuous murmur|| |
|Grading of murmur intensity |
|Levine grading scale||Intensity|
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.
- Uniform: unchanging intensity
- Crescendo: increasing intensity
- Decrescendo: decreasing intensity
- Crescendo-decrescendo: initial increase followed by a decrease in intensity
Frequency (pitch) 
- 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)
Certain maneuvers may be performed to elicit a change in the intensity of a murmur.
|Maneuvers and their effect on murmurs|
|Maneuver||Effect on cardiac parameters||Effect on murmurs|
Squatting/lying down quickly/raising the legs
Sitting and leaning forward
Lying down in the left lateral position
Exceptions to maneuvers
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
- Chest x-ray
- Cardiac MRI/CT
- Cardiac scintigraphy (especially in ischemic cardiac disease)
- Heart contour in the lateral view
- Heart contour in the posteroanterior (PA) view
- Cardiothoracic ratio (heart size)
- Assess the lung fields, e.g., for signs of pulmonary edema.
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) 
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 
- Myocardial biopsy