THE CARDIOVASCULAR EXAM PSD Nadine Gauthier, MD, Med, FRCPC Division of Cardiology

Specific Objectives 12077 - Describe a basic approach to the physical examination of the cardiovascular system including inspection, palpation and auscultation. 12078 - Explain the basic heart sounds. 12079 - Describe how to perform a blood pressure.

GENERAL OBJECTIVES Approach to CVS Exam Demonstrate the basic use of the stethoscope. Approach to Vital Signs Demonstrate how to properly measure the heart rate, and respiratory rate. Blood Pressure Measurement Demonstrate how to take an office blood pressure as per the Canadian Hypertension Program (CHEP). Approach to CVS Exam Explain a basic approach to the physical examination of cardiovascular system including inspection, palpation and auscultation. Demonstrate the normal location of the apical impulse. Demonstrate manoeuvres to elicit the apical impulse and auscultation of the heart.

WHERE TO START Must first understand the process and develop a systematic approach. Need to be able to recognize normal to diagnose abnormal. Head to toe approach.

Examining the Heart and Circulation Inspection General inspection Specific to CV Pulses Rate and rhythm BP JVP Height and waveform Carotids Palpate and auscultate Palpation Precordium and apex Location, size, abnormal impulses Auscultation Peripheral pulses Palpate and listen for bruits Examine extremities Arterial/venous insufficiency/atrophic changes

IS THE PATIENT STABLE? Elective Evaluation Acute Evaluation Comfortable/distressed Dyspneic/fatigued Pale/cyanosed Diaphoretic Dehydrated/volume depleted Congested/edematous/ volume overloaded Acute Evaluation A - Airway – patent/obstructed B - Breathing – rate/pattern C - Circulation – HR/BP D - Describe the patient

INSPECTION Cyanosis Clubbing Xanthoma and xanthelasma Stigmata of endocarditis Pectus excavatum/body habitus

Cyanosis Clubbing

DIFFERENTIAL DIAGNOSIS OF CLUBBING Cyanotic congenital heart disease Lung disease Cystic fibrosis Interstitial fibrosis Malignancy Sarcoidosis Bronchiectasis Hyperthyroidism

MARFAN’S SYNDROME Body Habitus Tall/thin/long facies Long fingers Thumb sign Wrist sign Ligamentous laxity Scoliosis/kyphosis Pectus excavatum/carinatum Ectopia lentis Narrow long facies High arched palate

PULSE

RADIAL PULSE Most common site to measure heart rate Palpate radial artery with index and middle finger for 15s then multiply x 4. If rate too rapid, slow or irregular rhythm palpate for full 60s. Normal rate: 60-100 ppm Tachycardia: ≥ 100 ppm Bradycardia: ≤ 60 ppm

RADIAL PULSE Cardiac rhythm If the rhythm is irregular, auscultation should be used Regular Irregularly irregular Regularly irregular Respiratory variability Carotid pulse is also very reliable to determine rhythm Carotid upstroke: volume and contour Reduced in aortic stenosis Increased in aortic regurgitation

REGULAR RHYTHM Normal Sinus Rhythm

IRREGULARLY IRREGULAR Atrial Fibrillation

REGURLARLY IRREGURLAR Ventricular Bigeminy

CAROTID PALPATION

CAROTID EXAMINATION Carotid upstroke Carotid auscultation Brisk, normal or delayed Volume: normal, increased or decreased Anacrotic or Bisferiens Carotid auscultation Bruit Transmitted murmur A2 audible in neck? Presence excludes severe AS

PULSE VOLUME & CONTOUR Palpate Describe: Forearm/Brachial/Carotid/Femoral Describe: Volume: normal/increased/decreased Slow rising +/- brachial-radial delay (aortic stenosis -AS) Collapsing or water hammer pulse - (aortic regurgitation -AR) Bifid (bisferiens –AS/AR or IHSS) Pulsus paradoxus Tamponade COPD Pulsus alternans LV dysfunction

BLOOD PRESSURE ASSESSMENT: PATIENT PREPARATION Standardized technique: Posture The patient should be calmly seated for at least 5 minutes, with his or her back well supported and arm supported at the level of the heart. His or her feet should touch the floor and legs should not be crossed. The patient should be instructed not to talk prior and during the procedure.

Arm circumference (cm) CUFF SIZE Arm circumference (cm) Size of Cuff (cm) From 18 to 26 9 x 18 (child) From 26 to 33 12 x 23 (standard adult model) From 33 to 41 15 x 33 (large, obese) More than 41 18 x 36 (extra large, obese)

RECOMMENDED TECHNIQUE FOR MEASURING BLOOD PRESSURE Locate brachial and radial pulse Position cuff at the heart level Arm should be supported

RECOMMENDED TECHNIQUE FOR MEASURING BP To exclude possibility of auscultatory gap, increase cuff pressure rapidly to 20-30 mmHg above level of disappearance of radial pulse Place stethoscope over the brachial artery

RECOMMENDED TECHNIQUE Drop pressure by 2 mmHg / sec Appearance of sound (phase I Korotkoff) = systolic pressure Record measurement Drop pressure by 2 mmHg / beat Disappearance of sound (phase V Korotkoff) = diastolic pressure Take 2 blood pressure measurements, 1 minute apart

RECOMMENDED TECHNIQUE Standardized technique: For initial readings, take the blood pressure in both arms and subsequently measure it in the arm with the highest reading. Thereafter, take two measurements on the side where BP is highest.

RECOMMENDED TECHNIQUE The seated blood pressure is used to determine and monitor treatment decisions. The standing blood pressure is used to test for postural hypotension: elderly, diabetics, diuretics. A fall in systolic BP > 10 mm Hg is significant

BP TREATMENT TARGETS CONDITION 160/100 Treatment threshold if no risk factors < 140/90 Normal office BP Treatment target for office BP measurement < 135/85 Normal Home BP Treatment target for for ABP or HBP measurement < 130/80 Treatment target for for Type 2 diabetics or non-diabetic nephropathy or CAD (AHA)

INDICATIONS FOR CHECKING THE BP IN BOTH ARMS? The presence of both arms R/O Atherosclerotic obstruction Scalenus anticus syndrome/cervical rib Aortic coarctation above left subclavian Anomalous origin right subclavian artery in aortic coarctation Fam Pract 2002 Oct;19(5):439-41 Related Articles, Links   The differential blood pressure sign in general practice: prevalence and prognostic value. Clark CE, Powell RJ. The Mid Devon Medical Practice, School Surgery, Fore Street, Witheridge, Devon EX16 8AH and Research & Development Support Unit, School of Postgraduate Medicine and Health Sciences, Noy Scott House, Haldon View Terrace, Exeter EX2 5EQ, UK. BACKGROUND: Patients sometimes have differences of >/=20/10 mmHg in their blood pressure depending on which arm is measured. The prevalence and prognostic value of this finding in general practice are unknown. If these differences are due to peripheral vascular disease, these patients may be at increased risk of cardiovascular or cerebrovascular events. OBJECTIVE: Our aim was to establish the frequency and prognostic value of a blood pressure difference between arms in one rural general practice. METHODS: Paired blood pressure readings were collected from patients attending the surgery. The outcome measures of myocardial infarction, new diagnosis of angina, a cerebrovascular event or death were recorded prospectively. RESULTS: A total of 280 patients were examined, and of these 13.6% had a systolic blood pressure difference (SBPD) of >/=20 mmHg, and 23.2% a diastolic blood pressure difference (DBPD) of >/=10 mmHg. Eighty-three patients were followed-up for 5.6 years. Patients with a DBPD of >/=10 mmHg showed a mean event-free survival of 3.3 years [95% confidence interval (CI) 2.2-4.4] compared with 5.0 years (95% CI 4.7-5.3) for those with a DBPD of <10 mmHg (P < 0.0001). Patients with an SBPD of >/=20 mmHg showed a mean event-free survival of 3.5 years (95% CI 2.3-4.7) compared with 4.9 years (95% CI 4.5-5.2) for an SBPD of <20 mmHg (P = 0.043). CONCLUSIONS: During a single assessment of blood pressure, there will be a minority of patients with a difference of >/=20/10 mmHg between their right and left arms. Measurement of both arms is therefore necessary to diagnose and treat hypertension accurately. This study suggests an association between blood pressure difference and increased morbidity and mortality. Priority should be given to managing other risk factors aggressively in those patients with a reproducible blood pressure difference of >/=20/10 mmHg.

BP IN THE LOWER EXTREMITIES? Who? Hypertensive patient under 40 years of age. Elderly patient with suspected PVD How do you do it? Thigh cuff-auscultate over popliteal artery Large arm cuff around calf palpate PT or DP

JUGULAR VENOUS PRESSURE Measured JVP height correlates with the central venous pressure Measurement of pressure in the right atrium Height of JVP in cm + 5 cm H2O = RA pressure External jugular is more visible than the internal jugular Reference point is the angle of Louis (2nd ICS) Requires 2 rulers, measure horizontal distance to reference point and then vertical height.

MORE ON JVP Patient position is key for proper assessment Patient at 30-45°degrees Head in slight extension, turn to the left Tangential lighting Right side of neck exposed Technique Look for double pulsation medial to external jugular vein Between the two heads of the SCM Above the clavicle Jugular venous pressure - IJV acts as a barometer - direct transmission of the pressure of RA seen as a blood column. IJV - medial to sternomastoid - not seen but the pulsations seen - top of the pulsating column indicates JVP EJV - not used because tortuous course in the thoracic cavity - subject to compression - not very accurate. Level of sternal angle is about 5 cm above the level of mid right atrium IN ANY POSITION. JVP measured in ANY position in which top of the column is seen easily. Usually JVP is less than 8 cm water - < 3 cm column above level of sternal angle.

Identification of the height of the column If JVP is not visible ABNORMAL JVP Normal JVP 3-4 cm above angle of Louis Identification of the height of the column If JVP is not visible Pressure too high: elevate the head of the bed to 90 degrees (column should drop with gravity) Pressure too low: lower the head of the bed (supine)

Proper positionning is key! External Jugular Vein

HAND MAND RULER

NORMAL JVP WAVEFORM 3 positive waves a c v 3 descents x x'(x prime) y

NORMAL JVP WAVEFORM "A" wave: atrial contraction (ABSENT in atrial fibrillation) "C" wave: ventricular contraction (tricuspid bulges). YOU WON'T SEE THIS "X" descent: atrial relaxation "V" wave: atrial venous filling (occurs at same of time of ventricular contraction) "Y" descent: ventricular filling (tricuspid opens)

Pulsation of the Carotid Pulse JVP VS. CAROTID Pulsation of the JVP Pulsation of the Carotid Pulse Rarely palpable Palpable Two waves, two descents Weak pulsation Strong upstroke, one descent Strong pulsation Compressible Non-compressible Height of column varies with patient positionning Position does not affect the height of the pulsation Abdominal-jugular reflux N/A Respiratory variation No respiratory variation

HEPATO-JUGULAR REFLUX AND KUSSMAUL’S SIGN Abdomino-jugular reflux (various definitions) sustained rise to 4 cm for 10 sec.  RV compliance Positive HJR correlates with LVEDP > 15 JVP normally falls with inspiration Kussmaul’s sign inspiratory  in JVP constriction rarely tamponade RV infarction Method Of Exam Author: A. ChandrasekharConsultant: R. Lichtenberg and R. Gunnar Inspect for internal jugular vein pulsations in the neck, in supine position and with neck and trunk raised to approximate angle of 45o. Internal jugular vein pulsation are visible at the root of the neck between clavicular and sternal heads of sternoclidomastoid muscle. Internal jugular vein corresponds to a line drawn from this point to infra auricular region. Inspection with simultaneous palpation of the carotid and/or auscultation of the heart will assist in identification and timing of the waves. Inspect the vein from different angles. Apply light tangentially and observe for venous pulsations in the shadow of neck on the pillow. At 0o jugular veins should be filled. An impulse visible just prior to S1 or the upstroke of the carotid is the "a-wave". This will be followed by a x-descent. The 'c' wave is usually not visible. The 'v' wave occurs after the start of the carotid upstroke and during ventricular systole (which is atrial diastole). When the tricuspid valve opens there is a brisk descent (y-descent). Observe the venous pressure changes with respiration. There is normally a drop in intrathoracic pressure with inspiration. This decrease is also reflected on the intracardiac pressures. Therefore, an increase in the pressure difference between the SVC/IVC and the RA increases cardiac filling. Normal: Neck veins are not visible at 45 o inclination. Neck veins should be visible in supine position. JVP should decrease with inspiration.

CAUSES OF ABNORMAL JVP Heart failure Pericardial effusion Right or left Pericardial effusion Pericardial constriction Tricuspid stenosis Hypervolemia Hyperthyroidism Fistula Pregnancy SVC obstruction SVC RA RV Pericardium

CARDIAC EXAM Inspection Palpation Scars Chest wall deformities: pectus excavatum Visible apical impulse Ventricular lifts (parasternal borders) Palpation Four zones Thrills: palpable murmurs Lifts: ventricular displacement due to dilatation Palpable P2 (pulmonary artery) Palpable S3, S4

PRECORDIAL PALPATION Sequence of auscultation: Upper right sternal border -2ICS (intercostal space) Upper left sternal border - 2ICS Parasternal (left sternal border 3rd - 5th ICS) Apex Apex left decubitus (patient rolled over halfway) Apex upright leaning forward

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PRECORDIAL PALPATION Parasternal: Apex Lift: RV enlargement or severe MR Thrill: VSD, HOCM (IHSS) Palpable P2 (ULSB): pulmonary hypertension Apex Location Size

PALPATION - APEX Apex Normal Location Normal Size Palpable in 1 of 5 adults < age 40 Best felt with fingertips or finger pads Normal Location No more than 10 cm from mid-sternal line in the supine position Left decubitus position not reliable for apical location Normal Size No larger than 3 cm (about 2 finger breadths)

APEX-DYNAMIC QUALITIES LV impulse moves outward like a ping pong ball protruding between the ribs Apex moves outward for the first third of systole and falls away rapidly Lasts for no more than 2/3 of systole Sustained apex: > 2/3 systole - hangs out to S2 correlates with LV pressure overload AS, LVH or LV systolic dysfunction

APEX – DYNAMIC ABNORMALITIES Hyperdynamic Apex: Correlates with volume overload AR/MR Palpable S4 (atrial kick) – stiff LV Loss of LV compliance LVH 2o Hypertension Aortic Stenosis Hypertrophic Cardiomyopathy Palpable S1 (MS) Palpable non-ejection click (MVP)

Auscultation

AUSCULTATION Use the diaphragm for high pitched sounds and murmurs Use firm pressure to bring out high pitched sounds and murmurs Use the bell for low pitched sounds and murmurs Use light pressure to bring out low pitched sounds and murmurs If using tunable diaphragm (Masters) Firm pressure for high pitched sounds Light pressure for low pitched sounds

AUSCULTATION Stethoscope diaphragm Stethoscope bell High pitch heart sounds S1, S2, murmurs of AS or regurgitant jets Pericardial rub Stethoscope bell Low pitch heart sounds S3, S4, mitral stenosis

SEQUENCE OF AUSCULTATION Upper right sternal border (URSB) with diaphragm Upper left sternal border (ULSB) with diaphragm Lower left sternal border (LLSB) with diaphragm Apex with diaphragm and then bell Apex - left lateral decubitus position with bell Lower left sternal border (LLSB)- sitting, leaning forward, held expiration with diaphragm

Aortic valve: Right upper sternal border– 2nd ICS Pulmonic valve: Left upper sternal border – 2nd ICS Tricuspid valve: Right lower sternal border – 4th ICS Mitral valve: Midclavicular line – 5th ICS Pulmonic Aortic Mitral Tricuspid

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The Cardiac Cycle

FIRST HEART SOUND S1 (M1, T1) Louder at the apex Loud S1 Soft S1 Mitral valve closure Loud S1 Mitral stenosis Tricuspid stenosis (rare) Tachycardia, exercise, anemia Soft S1 Mitral and tricuspid regurgitation Left ventricular dilatation Decreased heart sounds (obesity, COPD)

SECOND HEART SOUND S2 (A2, P2) Loudest at the base, RUSB, 2nd ICS Physiological split With inspiration, P2 closes later, A2-P2 widens With expiration, A2-P2 narrows again Wide split: pulmonic valve closes late (RBBB) Fixed split: ASD (more flow RA-RV) Paradoxal: P2-A2 wide in expiration (LBBB)

THIRD HEART SOUND S3 Physiologic or pathological Pathological: > 40 years old Volume overload Heart Failure Mitral regurgitation Positioning Left lateral decubitus, 5th ICS – LV Right parasternal border, 4th ICS – RV “MONTREAL” S3

Third Heart Sound S3

FOURTH HEART SOUND S4 Physiological or pathological Pathological S4 Pressure overload Resistance of ventricular filling due to the increase ventricular wall tension Decreased compliance Myocardial infarction Cardiomyopathy Hypertension Aortic stenosis “Toronto” Gallop S4, S1, S2, S3 S4

Fourth Heart Sound S4 Gallop

LISTEN FOR EXTRA SOUNDS Systolic extra sounds Ejection click Bicuspid aortic valve Aortic root Non Ejection click Mitral valve prolapse Diastolic extra sounds Wide split S2 Pericardial knock Opening snap of mitral stenosis

Timing of Cardiac Sounds

LISTEN FOR MURMURS What is a murmur? A sound/vibration made by blood flowing through a normal valve or an abnormal valve. A sound made by blood flowing backwards through a leaking valve Murmurs may be functional or pathologic

HEART MURMURS Approach to murmur description Timing of cardiac cycle (systole, diastole) Shape (Crescendo, decrescendo, holo or pansystolic) Loudest in specific cardiac zone depending on valve Radiation (jet direction) Intensity (Grade I-VI) Tone (high or low pitch) Quality (musical, harsh, blowing)

MURMUR INTENSITY I : very weak, barely audible II : audible but discrete III: loud murmur, audible for most IV: loud murmur with a thrill V: very loud, murmur audible with stethoscope partially applied to skin VI: audible with stethoscope not on chest wall

FUNCTIONAL MURMURS COMMON IN ASYMPTOMATIC ADULTS Characterized by Grade I – II @ LSB Systolic ejection pattern - no  with Valsalva Normal precordium, apex, S1 Normal intensity & splitting of second sound (S2) No other abnormal sounds or murmurs No evidence of LVH S1 S2

PATHOLOGIC MURMURS Diastolic murmur Loud murmur - grade 4 or above Regurgitant murmur Murmurs associated with a click Murmurs associated with other signs or symptoms e.g. cyanosis Abnormal 2nd heart sound – fixed split, paradoxical split or single

SYSTOLIC MURMURS Crescendo-Decrescendo B1 and B2 audibles Aortic or pulmonic stenosis Pansystolic Starts with B1 and finishes on B2 Tricuspid and mitral regurgitation Late systolic Starts in mid-systole and extends to S2 Mitral valve prolapse Non-ejection click B1 B2

Systolic Murmurs

AORTIC STENOSIS Carotid pulse Palpation Ausculatation Decrease volume and contour (with  severity) Palpation Sustained apex LV hypertrophy Ausculatation Soft S2 S4 Crescendo-decrescendo murmur RUSB, 2nd ICS Radiates to carotid and apex Murmur peaks later in systole with  severity B1 B2 B4

MITRAL INSUFFICIENCY Carotid pulse Palpation Auscultation Low volume Hyperdynamic contour Palpation Enlarged apex Auscultation Soft S1 S3 Holosystolic murmur at the apex radiates to axilla or RLSB B1 B2 B3

DIASTOLIC MURMURS Early decrescendo Starts with S2, finished mid-diastole Aortic or pulmonic regurgitation Mid diastolic Turbulent flow across AV valves Volume overload Diastolic rumble, MS B1 B2 B1 B2

Diastolic Murmurs

CHEST EXAMINATION Part of a complete cardiovascular examination Respiratory distress Use of accessory muscles Identify presence of heart failure Fine crackles at the base Crackles throughout with respiratory distress = pulmonary edema Wheezing can also be seen with CHF Bronchospasm

ABDOMINAL EXAM Inspection Ausculatation Palpation Jaundice Ascites Pulsatile liver or mass Ausculatation Abdominal bruits Palpation Pulsatile liver: right CHF, fluid overload AAA

LOWER PERIPHERAL EXAM Peripheral pulses Peripheral edema Pitting – right CHF, bilateral Non-pitting – venous insufficiency – bilateral Unilateral – not cardiac

EXAMINATION OF PULSES Grading: Trophic changes/Ulceration Perfusion Normal/Increased/Decreased/Absent 2+/3+/1+/0 Allen’s test Trophic changes/Ulceration Perfusion Pallor on elevation Rubor on dependency Venous refill with dependency (should be less than 30 seconds) Bruits

PERIPHERAL PULSES Femoral arteries Brachio-femoral delay: aortic coarctation Increased pulse: “bounding” in aortic regurgitation Pedal pulses: dorsalis pedis, posterior tibialis Decreased with peripheral arterial disease

ANKLE-BRACHIAL INDEX Resting and post exercise SBP in ankle and arm. Normal ABI > 1 ABI < 0.9 has 95% sensitivity for angiographic PVD ABI 0.5- 0.84 correlates with claudication ABI < 0.5 indicates advanced ischaemia

MEASUREMENT OF THE ABI Figure 1. Measurement of the Ankle-Brachial Index (ABI). Systolic blood pressure is measured by Doppler ultrasonography in each arm and in the dorsalis pedis (DP) and posterior tibial (PT) arteries in each ankle. The higher of the two arm pressures is selected, as is the higher of the two pressures in each ankle. The right and left ankle-brachial index values are determined by dividing the higher ankle pressure in each leg by the higher arm pressure.16 The ranges of the ankle-brachial index values are shown, with a ratio greater than 1.30 suggesting a noncompressible, calcified vessel. In this condition, the true pressure at that location cannot be obtained, and additional tests are required to diagnose peripheral arterial disease. Patients with claudication typically have ankle-brachial index values ranging from 0.41 to 0.90, and those with critical leg ischemia have values of 0.40 or less. Hiatt W. N Engl J Med 2001;344:1608-1621

Trophic Changes Shiny, hairless skin, dystrophic nail changes and dependent rubor associated with peripheral arterial occlusive disease.

Pallor on elevation Rubor on dependency

Digital Ischaemia Gangrene

Venous Insufficiency

VENOUS ABNORMALITIES VARICES AND SPIDER VEINS

TYPES OF EDEMA

Cellulitis vs DVT Cellulitis Right Deep Venous Thrombosis

IMPORTANT RESOURCES