Examination Of The Cardiovascular System

Examination of the Cardiovascular System

Signs of Heart Disease Although the cardiovascular examination centers on the heart, peripheral signs often provide important information

Appearance • Cardiac patients may appear healthy and comfortable at rest, many with acute myocardial infarction appear anxious and restless • Diaphoresis suggests hypotension or a hyperadrenergic state, such as during pericardial tamponade, tachyarrhythmias, or myocardial infarction • Cold and clammy skin or pallor suggests low cardiac output and may be a sign of cardiogenic shock or anemia • Patients with severe chronic CHF or other long-standing low cardiac output states may appear cachectic

• Cyanosis : Central, due to arterial desaturation e.g. pulmonary disease, left heart failure, or right-to-left intracardiac or intrapulmonary shunting Peripheral, reflecting impaired tissue delivery of adequately saturated blood in low-output states, polycythemia, or peripheral vasoconstriction • Clubbing may be present in chronic cyanotic states • Edema may be present and its nature and extent is noted. Also note if presacral edema is present. Severe right heart failure may also present with ascites and scrotal edema

Vital Signs Heart rate

• Normal resting heart rate usually ranges from 50 to 90 beats/min • Slower and more rapid rates may occur in normal individuals or may reflect noncardiac conditions such as anxiety or pain, medication effect, fever, thyroid disease, pulmonary disease, anemia, or hypovolemia

Blood Pressure • The range of normal BP is wide, but even in asymptomatic individuals systolic pressures below 90 mm Hg or above 140 mm Hg and diastolic pressures above 90 mm Hg warrant further clinical evaluation and follow-up • Anxiety may increase the BP, and the patient should be asked if it has been checked in other settings

Respiratory rates • Tachypnea is also nonspecific, but pulmonary disease and heart failure should be considered when respiratory rates exceed 16/min under resting conditions • Cheyne–Stokes respiration, a form of periodic breathing is not uncommon in severe heart failure

Peripheral Pulses • The arterial pulse is examined for the rate, rhythm, amplitude and wave form • The radial pulse is sufficiently obvious for analysis of rate and rhythm. The left and right radial pulses are simultaneously to check for discrepancies between the two sides • The amplitude and wave form of the aortic pulse are best assessed by palpation of the carotid arteries

Types of arterial pulse

• Carotid pulse: – – – –

incline the head to relax sternomastoid on the palpated side feel medial to sternomastoid and lateral to the upper trachea or lower larynx the laryngeal prominence may be used as a landmark; palpate lateral to this never palpate bilaterally

• Brachial pulse - a third of the way over from the medial condyle • Radial pulse - medial to the radius • Femoral pulse - below inguinal ligament; a third of the way up from pubic tubercle • Popliteal pulse - with knee flexed at right angles palpate deep in the midline • Posterior tibial pulse - 1cm behind medial malleolus • Dorsalis pedis pulse - variable on dorsum, just lateral to tendons to big toe

Pulse Rate • Tachycardia is defined as a pulse rate of >100 beats per minute • An abnormally fast pulse has various possible causes: 1. sinus tachycardia - the rhythm is normal 2. cardiac arrhythmias causing tachycardia where the rhythm is not normal • Bradycardia is a slow heart rate; a pulse rate of less than 60 beats per minute in an adult • Possible situations include: 1. sinus bradycardia - where the abnormally slow pulse is the result of pacemaking from the sinoatrial node. This occurs in situations such as increased intracranial pressure, jaundice, sinoatrial disease, hypothyroidism and in trained athletes 2. atrioventricular dissociation - this occurs in situations such as heart block and rarely, hypothermia

Pulse Rhythm • The rhythm of the normal pulse is regular apart from sinus arrhythmia that is most often seen in youth • Sinus arrhythmia is the slight speeding up of the pulse on inspiration and the slight slowing of the pulse rate on expiration • Regularly Irregular pulse occurs in ectopic beats. • An irregularly irregular pulse occurs in atrial fibrillation • Sinus rhythm with multiple extrasystoles may simulate irregularly irregular pulse • Exercise accentuates the irregularity of the pulse seen in atrial fibrillation; extrasystoles disappear during exercise, unless the subject has severe myocardial disease

Pulse Amplitude •

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• Arterial pulse (amplitude, large)    With the patient reclining, the examiner raises the patient's arm vertically upwards. The examiner grasps the muscular part of the patient's forearm The Corrigan or waterhammer pulse or collapsing pulse is felt as a tapping impulse which is transmitted through the bulk of the muscles. A waterhammer was a Victorian toy in which a tube was half filled with fluid, the remainder being a vacuum. The child would invert and reinvert the tube; each time the impact of the fluid at each end would sound like a hammer blow E.g. aortic regurgitation

• Arterial pulse (amplitude, small)    • Possible conditions which can cause a small amplitude arterial pulse include: 1. a small left ventricular volume - in conditions such as shock, tachycardia, left ventricular dysfunction, mitral stenosis 2. aortic stenosis - due to obstruction of left ventricular ejection 3. severe pulmonary stenosis

Arterial pulse (wave forms) The wave form felt by the finger depends on

the rate of change of pressure (dP/dt) rather than the pressure wave recorded • The normal arterial wave form has a smooth, fairly sharp upstroke, a momentarily sustained peak and a quick downstroke • A dicrotic pulse is one in which two impulses are felt for each heartbeat • Although this dual waveform is found in the normal subject, it is only clinically apparent in pyrexic patients. • Abnormal wave forms are usually due to

Normal arterial wave form

Dicrotic pulse

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Slow rising pulse   

• This wave form is characterized by a slow upstroke • The time taken to reach the peak is prolonged and the entire wave is flattened and of small amplitude • Possible causes include :- • aortic valve stenosis - in this condition the rate of ejection of blood into the aorta is decreased so that the duration of the ejection is prolonged. The amplitude of the pulse is diminished as a consequence. – • poorly functioning left ventricle may give rise to a slow rising wave form due to slow ejection from the poorly functioning ventricle

Slow rising pulse

• Sharp rising pulse    • In this wave form the upstroke is abrupt and steeper than normal • The peak of the wave form is reached earlier than normal and there is a rapid downstroke • The amplitude of the wave form is abnormally wide • Example: waterhammer pulse in Aortic insufficiency

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Bisferiens Pulse

In the bisferiens wave form there are two pressure peaks an initial sharp upstroke a small decrease in pressure a second peak, similar to the first a decrease in pressure down to baseline

• This wave form has a large amplitude and the examiner should be able to feel two distinct impulses with each pulse beat. • This pulse is particularly well felt at brachial level. • Observed in patients with hemodynamically significant (but not mild) aortic regurgitation and in patients with mixed aortic stenosis and aortic regurgitation, bisferiens pulse occurs when regurgitation is the predominant lesion • Also in hypertrophic obstructive cardiomyopathy.

Example of Bisferiens pulses

Pulsus paradoxus • This is an exaggeration of the normal pattern whereby the systolic pressure and the pulse pressure fall during inspiration • Normally the decrease in systolic pressure as measured by a sphygmomanometer is less than 10 mmHg. • Pulsus paradoxus is occasionally observed in patients with obstructive airways disease and pericardial tamponade

Pulsus alternans • Pulsus alternans is a variation in pulse amplitude occurring with alternate beats due to changing systolic pressure. • Amplitude of the pulse alternates every other beat during sinus rhythm, occurs when cardiac contractility is very depressed • The most important cause of pulsus alternans is left ventricular failure

Unequal pulses Radiofemoral delay: • The radial and femoral pulses are palpated simultaneously. • An appreciable delay in the femoral pulse is suggestive of coarctation of the aorta. • Coarctation of the aorta may lead to hypertension in the circulatory system serving the head and upper limbs

Absent radial or brachial pulse • Radial pulse may be absent in: • situations where there has been a surgical procedure, for example in Blalock Taussig shunting, where one of the radial pulses may be absent. • congential absence of one of the pulses; for example in Holt-Oram syndrome - in association with absent radius • Embolization and cervical rib

Diminished peripheral pulses most commonly result from arteriosclerotic peripheral vascular disease and may be accompanied by localized bruits

Jugular venous pulsations (JVP) • The jugular venous pressure (JVP) provides an indirect measure of central venous pressure • It is preferable to examine the internal rather than external jugular veins since valves located between the superior vena cava and the external jugular veins interfere with pressure transmission, also, the external jugular venous bulb also is a site for thrombus formation, which is a cause for partial obstruction of the external jugular veins • The JVP consists of certain waveforms and abnormalities of these can help diagnose certain conditions.

How to examine the JVP • Use the right internal jugular vein (IJV) • Patient should be at a 45° angle • Head turned slightly to the left • If possible have a tangential light source that shines obliquely from the left • Locate the surface markings of the IJV - runs from medial end of clavicle to the ear lobe under medial aspect of the sternocleidomastoid • Locate the JVP - look for the double waveform pulsation (palpating the contralateral carotid pulse will help) • Measure the level of the JVP by measuring the vertical distance between the sternal angle and the top of the JVP. Measure the height - usually less than 3cm.

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Waves

• a - presystolic; produced by right atrial contraction • c - bulging of tricuspid valve into the right atrium during ventricular systole (isovolumic phase) • v - occurs in late systole; increased blood in right atrium from venous return

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Descents

• x - combination of atrial relaxation, downward movement of the tricuspid valve and ventricular systole • y - tricuspid valve opens and blood flows in to the right ventricle • The a and v wave can be identified by timing the double waveform with the opposite carotid pulse. The a wave will occur just before the pulse and the v wave occurs towards the end of the pulse. Distinguishing the c wave, x and y descents is an almost impossible task.

JVP

How to differentiate a jugular venous pulse from the carotid pulse • The JVP pulse is: • Not palpable • Obliterated by pressure • Characterised by a double waveform • Varies with respiration - decreases with inspiration • Enhanced by the hepatojugular reflux

Hepatojugular reflux (abdominojugular reflux sign) the pulsation is caused by the JVP • This can help confirm that • Firm pressure is applied to the right upper quadrant using the palm of the hand • A transient increase in the JVP will be seen in normal patients • There may be a delayed recovery back to baseline which is more marked in right ventricular failure • Kussmaul's sign (failure of jugular venous pressure to decrease with inspiration) is commonly seen with RV infarction, postoperatively after cardiac surgery, with tricuspid regurgitation, and with constrictive pericarditis.

Causes of a raised JVP • Heart failure • Constrictive pericarditis (JVP increases on inspiration called Kussmaul's sign) • Cardiac tamponade • Fluid overload e.g. renal disease • Superior vena cava obstruction (no pulsation)

Abnormalities of the JVP

• Abnormalities of the a wave • Prominent a waves imply poor RV compliance or atrial contraction against a closed tricuspid valve (due to AV dissociation associated with ventricular arrhythmias, pacing, or tricuspid stenosis) • Disappears in atrial fibrillation • Large a waves occur in any cause of right ventricular hypertrophy (pulmonary hypertension and pulmonary stenosis) and tricuspid stenosis • Extra large a waves (called cannon waves) in complete heart block and ventricular tachycardia

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• Prominent v waves A prominent v wave implies rapid filling of the RA, such as in an atrial septal defect (ASD) or mild tricuspid regurgitation c-v wave implies significant tricuspid regurgitation • Slow y descent Tricuspid stenosis Right atrial myxoma • Steep y descent Right ventricular failure Constrictive pericarditis Tricuspid regurgitation (The last two conditions have a rapid rise and fall of the JVP called Friedreich's sign)

Jugular venous pulsations (JVP)

Precordial Pulsations • A parasternal lift usually indicates right ventricular hypertrophy (RVH), pulmonary hypertension (pulmonary artery [PA] systolic pressure > 50 mm Hg), or LA enlargement; PA pulsations may also be visible • The examiner should feel the LV apical impulse in the left lateral position and note if it is sustained or enlarged • If the second heart sound is palpable along the left sternal border, it may imply an increased P2 and pulmonary hypertension.

Heart Sounds & Murmurs • Auscultation is helpful in the diagnosis of many heart diseases, and provides evidence for cardiac failure • The first heart sound (S1): • Produced due to the closing of the mitral valve and tricuspid valve • It may be diminished with severe LV dysfunction or accentuated with mitral stenosis or short PR intervals.

• The Second heart sound (S2): • Produced due to the closing of the aortic valve and pulmonary valve • Separation of the components of S2 is due to the normally compliant lung, allowing for continuing forward cardiac output with systole compared to the stiffer arterial system. The pulmonary valve closes later than the aortic valve for that reason (splitting) • Inspiration increases flow to the lung and reduces flow to the left heart, and splitting is increased • Splitting may be fixed in atrial septal defect , wide with right bundle branch block, and absent or reversed (paradoxic splitting) with aortic stenosis, LV failure, or left bundle branch block • With normal splitting, an accentuated P2 is an

• Third and fourth heart sounds: • They indicate ventricular volume overload or impaired compliance and may be heard over either ventricle • An apical S3 is a normal finding in younger individuals and in high output states, such as pregnancy • Additional auscultatory findings include sharp, high-pitched sounds classified as "clicks."

Murmurs • Murmers indicate valvular disease • Innocent murmurs • A soft, short systolic murmur, usually localized along the left sternal border or toward the apex, may be innocent, reflecting pulmonary or aortic flow • They often vary with inspiration, diminish in the upright position, and are most frequently heard in thin individuals

Systolic murmurs • They should be classified as "holosystolic" when they merge with S1 and persist through S2 or "ejection" when they begin after S1 and end before S2 • Holosystolic murmurs tend to have a uniform intensity during systole, while ejection murmurs have a peak at some part of the systolic cycle • Holosystolic murmurs usually represent mitral regurgitation if maximal at the apex or in the axilla and tricuspid regurgitation or ventricular septal defect (VSD) if best heard at the sternal border. • Short aortic ejection murmurs with a preserved A2 are common in older individuals, especially when hypertension has been present, and even if they are moderately loud they usually reflect thickening (sclerosis) of the valve rather than stenosis

Diastolic murmurs • They are always clinically significant • High-pitched diastolic murmurs imply flow from a highpressure to low-pressure chamber (ie, pulmonic regurgitation in pulmonary hypertension, aortic regurgitation, or VSD) • Low-pitched diastolic "rumbles" imply filling across an AV valve (ie, mitral stenosis) • Association of murmurs with palpable vibrations ("thrills") is always clinically significant