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

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

3. 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.

4. 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.

5. 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

6. 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

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

8. Cyanosis
Clubbing

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

12. 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

13. PULSE

14. 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: ppm
Tachycardia: ≥ 100 ppm
Bradycardia: ≤ 60 ppm

15. 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

16. REGULAR RHYTHM
Normal Sinus Rhythm

17. IRREGULARLY IRREGULAR
Atrial Fibrillation

18. REGURLARLY IRREGURLAR
Ventricular Bigeminy

19. CAROTID PALPATION

20. 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

21. 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

22. 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.

23. 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)

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

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

26. 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

27. 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.

28. 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

29. 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)

30. 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) ] compared with 5.0 years (95% CI ) for those with a DBPD of <10 mmHg (P < ). Patients with an SBPD of >/=20 mmHg showed a mean event-free survival of 3.5 years (95% CI ) compared with 4.9 years (95% CI ) 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.

31. 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

32. 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.

34. 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.

35. 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)

36. Proper positionning
is key!
External Jugular Vein

38. HAND MAND RULER

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

40. 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)

41. 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

42. 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.

43. 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

44. 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

45. 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

46. 1 2 3 4

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

48. 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)

49. 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

50. 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)

51. Auscultation

52. 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

53. 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

54. 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

55. 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

56. 1 2 3 4

57. The Cardiac Cycle

58. 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)

59. 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)

60. 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

61. Third Heart Sound S3

62. 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

63. Fourth Heart Sound S4 Gallop

64. 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

65. Timing of Cardiac Sounds

66. 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

67. 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)

68. 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

69. FUNCTIONAL MURMURS COMMON IN ASYMPTOMATIC ADULTS
Characterized by
Grade I – 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
S S2

70. 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

71. 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

72. Systolic Murmurs

73. 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

74. 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

75. 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

76. Diastolic Murmurs

77. 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

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

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

80. 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

81. 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

82. 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 correlates with claudication
ABI < 0.5 indicates advanced ischaemia

83. 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:

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

85. Pallor on elevation
Rubor on dependency

86. Digital Ischaemia Gangrene

87. Venous Insufficiency

88. VENOUS ABNORMALITIES VARICES AND SPIDER VEINS

89. TYPES OF EDEMA

90. Cellulitis vs DVT
Cellulitis
Right Deep Venous Thrombosis

91. IMPORTANT RESOURCES