- Clinical science
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 . For specific auscultatory findings of heart defects, see . Details regarding the specific signs and symptoms of cardiovascular disease can be found in the links provided below.
- The patient should be in supine position, torso elevated to 45 degrees, and the head extended backward and turned to the left (the neck veins should not be visible and collapse in this position).
Physiological JVP: waveform with the following components
- a wave → atrial contraction causes a peak in JVP; absent in atrial fibrillation
- c wave → RV contraction → closed tricuspid valve bulges into atrium → second peak in JVP
- x descent → atrial relaxation and ventricular contraction → inferior displacement of closed tricuspid valve → a drop in JVP; absent in tricuspid regurgitation
- v wave → increased right atrial pressure during filling period against the closed tricuspid valve; prominent in tricuspid insufficiency and right heart failure
- y descent → RA pressure decreases as blood is pumped into the right ventricle; prominent in tricuspic insufficiency, and constrictive pericarditis; absent in cardiac tamponade, and tricuspid stenosis
- Evaluation of pathological JVP: > 4 cm is considered elevated.
- The patient should be sitting for several minutes before measuring blood pressure.
- Use correct cuff size.
- The patient should be asked to rest his/her straight arm horizontally on a surface at heart level.
- Record the pressure in both arms (and legs) and note any differences.
- Determine the systolic and diastolic blood pressure value.
- Repeat measurement.
- 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 onfor details regarding normal and pathologic blood pressure values.
Possible sources of errors in blood pressure measurement
- 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.
A pulse wave is produced by ventricular contraction during systole.
- Three finger method: palpation with 2nd–4th fingertips
- Palpation of the common carotid artery, radial artery, abdominal aorta, femoral artery, popliteal artery, tibialis posterior artery, and dorsalis pedis artery.
- The pulse of the carotid artery should NEVER be palpated bilaterally and simultaneously!
Characteristics of pulse
|Rate|| || |
|Rhythm|| || |
Pulse volume (amplitude)
|Pulse wave tension|
|Speed of pulse upstroke (wave contour)|
- For detection of vascular murmurs in the carotid artery, abdominal aorta, renal artery, and femoral artery
- Causes of vascular murmurs: alteration of local vessels and vascular walls
- In cases of stenosis of > 60%
- Auscultation of high-frequency, pulse-synchronous sounds proximal to the stenosis
- Auscultation of low-frequency sounds distal to the stenosis
- Cause: atherosclerosis (> 90% of cases of peripheral vessel stenosis), aneurysms, vasculitis, compression syndromes (e.g., tumors in the surrounding tissue)
- Hypercirculation and increased cardiac output
|Site of auscultation||Distinctive characteristics of vascular murmur|
|Common carotid artery|| |
|Subclavian artery|| || |
|Abdominal aorta|| || |
|Renal artery|| |
|Common iliac artery|| || |
|Femoral artery|| |
|Popliteal artery|| |
The patient is initially requested to remove their upper body attire to identify:
- 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.
- Parasternal heave: a heaving motion felt over the left parasternal area (palpate with right hand and straightened elbow)
- Thrills: a palpable murmur, usually over the region where the heart murmur is heard best (see below)
- Palpable heart sounds: : palpate over valve areas (e.g., palpable P2: see below)
- Palpable vibrations: arising from loud murmurs that are located over the typical
- Suprasternal pulsations: visible or palpable pulsations over the sternoclavicular joint or suprasternal region (associated with aortic arch aneurysm)
- Epigastric (subxiphoid) pulsations: visible or palpable pulsations over the epigastric region of the abdomen (associated with right ventricular hypertrophy or 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.
- 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:
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.
|Primary heart sounds|
|1st heart sound (S1)|| || |
|2nd heart sound (S2)|| |
|Extra heart sounds (gallops)|
|3rd heart sound (S3)|| |
|4th heart sound (S4)|| |
- 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.
- Loud S1
- Soft S1
- Variable intensity
- S2 intensity
Splitting of heart sounds
- If the aortic and pulmonary valves do not close simultaneously, an apparent splitting of S2 can be heard upon auscultation.
|Splitting of S1|| |
|Splitting of S2||Physiological split|| |
| || |
Paradoxical split (reversed split)
Ejection sounds (Clicks)
Clicks are crisp sounds produced by the movement of abnormal valves.
|Mechanism||Timing||Technique of auscultation|
|Aortic ejection click|| || |
|Mitral valve opening snap|| || |
|Mitral valve prolapse click|| || |
|Mechanical valve clicks|| || || |
The absence of a click in patients with prosthetic valves may indicate valve failure!
Other abnormal heart sounds
- See .
- See .
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)
|Cause|| || |
| || |
|Timing|| || |
|Position change|| || |
|Region||Site at which a murmur is heard best||Pathology|
|Erb's point (cardiology)|| |
|Aortic region|| |
|Pulmonary region|| || |
|Mitral region|| |
|Tricuspid region|| || |
|Gibson's point|| || |
"All Physicians Earn Too Much" (Aortic, Pulmonary, Erb's point, Tricuspid, Mitral)
|Systolic murmurs|| |
|Diastolic murmurs|| || |
|Continuous murmurs|| || || |
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!
- Uniform: unchanging intensity
- Crescendo: increasing intensity
- Decrescendo: decreasing intensity
- Crescendo-decrescendo: initial increase, followed by decrease in intensity (rhombus-shaped)
- Aortic stenosis: systolic murmur radiates to carotid arteries
- Mitral regurgitation: systolic murmur radiates to the left axilla (in the left lateral recumbent position)
- Pulmonary stenosis: systolic murmur radiates to the interscapular region
The frequency of a murmur is dependent on the velocity of turbulent flow, which in turn is affected by the pressure gradient.
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|
Squatting/lying down quickly/raising the legs
Sitting leaning forward
Lying down in the left lateral position
Chest x-ray: shows the heart shadow (the transverse diameter of the heart shadow in the PA view should be no greater than one-half of the transverse diameter of the thorax)
- Heart contour in the lateral view
- Heart contour in the PA view
Echocardiography: done as (TTE) or (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
- 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
- Determine the average pressure gradient
- 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)
(to assess cardiac arrhythmias)
- The cardiac arrhythmia is often treated (e.g., by ablation) during the test itself.
- Myocardial biopsy