Table 6: Cardiovascular Exam

Physical Sign / Manoeuvre	Subsets	Rationale	Technique(s)	Interpretation	Evidence	Pre-Clerkship	Clerkship
Inspection
Peripheral cyanosis		Multiple etiologies	Hands and feet	increased extraction of O2 from blood at the peripheries Anemic patients would require more deoxyhemoglobin to have the same amount of cyanosis		4	4
Central cyanosis		Multiple etiologies	Lips, oral mucosa	Blood that leaves the heart deoxygenated (causes of increased AaDO2) If Hb is 120, then central cyanosis indicates pO2= 45 mm HG	Kelman, 1966. Detects deoxyhemoglobin level of 23.8 +LR = 7.4 -LR = 0.2	4	4
Pallor		Anemia	Conjunctival, nail beds, palm, conjunctival rim pallor	Pallor should be examined at the palmar creases and in the conjunctiva, however no sign has –LR less than 0.5 so anemia can never be ruled out	Palmar crease pallor +LR=9.0 Pallor at multiple sites +LR=4.5 Facial pallor in light skinned persons +LR 3.8 Nail bed pallor +LR 1.8 Conjunctiva rim pallor +LR=16.7 Nardone, 1990. Gjorup, 1986.	4	4
Edema	Systemic versus regional	High systemic venous pressures, hypo-albuminemia, obstruction to venous flow, lymph-edema, vascular permeability	Pressure applied for minimum of 1 to 2 seconds to area involved or dependent area McGee, 2007, Chapter 52.	A positive sign if depression that is seen and felt lasting more than 2 to 3 seconds	Edema that pits easily and rebounds within 2 to 3 seconds is due to low protein. Henry, 1978. The finding of pitting edema by itself without the knowledge of JVP height is an unreliable sign of cardiac disease. Harlan, 1977. Zema, 1980.	4	4
Clubbing		Cyanotic heart disease, endocarditis	See resp section	Should not be a routine part of a cardiac exam	Consists of less than 10% of all causes of clubbing Dickinson, 1993.	4	4
Vital Signs
Blood pressure	Auscultatory gap White coat effect		Indirect sphygmo-manometer	Identify hypertension	Hemmelgan, 2004.	4	4
	Pulsus Paradoxus	A exaggerated increase in BP difference between inspiration and expiration; Multiple etiologies including cardiac tamponade, right ventricular infarction, asthma PE, and uncommonly constrictive pericarditis	When assessing BP in the usual way, 1st note the BP at the appearance of Korotkoff sounds on expiration only; then note the BP again when Korotkoff sounds appear in inspiration and expiration. The difference should be less than 12 mmHg	Tamponade: +LR = 5.9; -LR – 0.03 Severe Asthma; + LR = 2.7; - LR = 0.5	McGee, 2007, Chapter 13.	2	4
Pulse Assessment
Pulse character	Regular versus irregular amplitude rate	Intermittent ectopy, pulsus altermans
Respiration Rate	Cheyne Stokes respiration	CHF versus neurological disorders			Patients with Cheyne stokes respiration have lower cardiac outputs, higher wedge pressures, and short survival McGee, 2007, Chapter 17.	3	4
Neck
Inspection of Neck Veins and Carotid Pulse	Inferring the CVP	Measurement of the JVP is useful because it infers the CVP, which is equal to the right ventricular end diastolic pressure	Method of Lewis (CVP equals JVP measured from the sternal angle + 5cm)	>3 cm is abnormal; Physicians tend to underestimate the CVP if measurement taken at semi-reclined position. Amoroso, 1989. Haywood, 1991.	Users are better able to locate the angle of Lewis than the phlebostatic axis; Drake, 1974. but sternal angle to phelbostatic axis varies with patient factors. McGee, 1998.	4	4
	Locating the top of the JVP		Using sternal angle (angle of Lewis)	Multiple uses the error of the JVP/CVP estimate can be up to 50%.	Clinical estimates of CVP usually within 4cm of catheter estimates 85% of the time Davison, 1974.	4	4
	Normal JVP versus elevated JVP		>3cm above the sternal angle OR Should be right atrium	If physician believes JVP elevated, LR = 9.0 JVP really elevated by catheter; conversely if physician believes JVP normal, LR = 0.1 CVP will be less than 12 cm by catheter Physicians can make useful judgements about CVP at the bedside despite a wide error margin	Davison, 1974. Cook, 1996.	4	4
What about JVP waveform?	X' dominant normal	CV wave in afib, TR	Brisk X'/Y in tamponade	See http://www.cvtoolbox.com/cvtoolbox2/physexam/phy_5.html	Constant, 2003.
	Kussmaul’s Sign (paradoxical elevation of JVP inspiration) HJR+	Constrictive pericarditis, severe heart failure, PE, right ventricular infarction Validity of the Hepato-jugular Reflux as a Clinical Test for Congestive Heart Failure	JVP that increases in height in inspiration	Likely has to do with a failure to accommodate increase venous return due to increased venous tone, decreased venous volume, and inability of right heart to compensate Operational characteristics not well defined	Observational evidence in each of the following disorders Constrictive pericarditis: Lange, 1966. Severe Heart Failure: Hitzig, 1941; Wood, 1961; Ducas, 1983. PE Dell’Italia, 1983; Lorell, 1979. Right Ventricular MI: Burdine, 1965. Ducas, 1983.	2	3
Carotid upstroke	Delayed/anacrotic =AS	Brink/increased volume =AR	Bifid AS/AR or IHSS
Carotid Bruit		Detection of atherosclerotic disease in the carotid artery	Listen high in the neck to differentiate between heart murmurs and bruits; also listen at the bifurcation of the carotid artery near the thyroid cartilage; the bell of the stethoscope should be used Orient, 2005, p397.	High grade stenosis in symptomatic patients:+LR = 1.5 to 3.2; LR = 0.6 to 0.3 Although only 50% of asymptomatic patients with a bruit actually have carotid stenosis; the presence of a bruit alone may be associated with a 3 to 6x incidence of stroke Orient, 2005, p399.	Sauve, 1993.
Precordial Exam
Percussion not performed	Cardiac size	Poor diagnostic utility and uncertain clinical significance			+LR = 2.4 to 2.5; -LR = 0.05 to 0.1 McGee, 2007, Chapter 33.	1	1
Palpation of the Precordium	Four cardinal positions	Thrills, palpable heart sounds and extra heart sounds such as s3 and s4.	Aortic, pulmonary, tricuspid, and mitral areas	Useful to rule out pulmonary hypertension in MS	Palpable P2 argues for pulmonary hypertension in MS +LR = 3.6, -LR = 0.05 Whitaker, 1954.	3	4
	Palpable S2	Pulmonary hypertension		See auscultation of loud s2	Detects pulmonary pressures of >50mmHg in patients with MS +LR=3.6, -LR = 0.5 Whitaker,1954.	2	3
	Size of apex		Left lateral decubitus position at 45 degrees, diameter of 4cm of more	The location of the apex is a better marker of left end diastolic volume. May be done in left lateral decubitus position Bethel, 1973.	Increased left end diastolic volume. +LR = 4.7 Dans, 1995. Eilen, 1983.	2	4
	Location of apex 12 cm from MSL/2.5-3 cm diameter	Point of maximal impulse does not relate to anatomical apex of heart	Supine; Measured from the mid-clavicular line Naylor, 1987.	PMI located outside midclavicular line implicates enlarged, failing heart or volume overload with normal EF A displaced apex is useful for detecting enlarged hearts Palpable in only 25% to 50% of adults regardless of position McGee, 2007, Chapter 34.	Enlarged heart on CXR +LR = 3.4 Mulkerrin, 1991. O’Neill, 1989. Ejection fraction is depressed +LR = 5.7 Gadsboll, 1989. Mattleman, 1983. LV end diastolic volume is increased +LR = 8.0 Gadsoll, 1989	3	4
	Amplitude of apex	Increase implies volume overload=AR, MR, VSD	Subjective process	In patient with known mitral stenosis, an increased apex argues for associated aortic stenosis OR mitral regurgitation General utility is not high.	+LR = 11.2 Wood, 1954.	1	1
	Sustained Apex	Detects left sided pressure or volume overload; aortic aneurysm; cardiomyopathy; pulmonary hypertension	Supine position; the distention of the precordium extends to S2 or beyond	A useful sign in very specific circumstances such as in aortic murmurs. Up to half of normal pts have sustained apex in left lateral decubitus position Boicourt, 1965.	In the presence of aortic murmur, sustained apex argues for aortic stenosis +LR = 4.1 Forssell, 1985. In the presence of aortic regurgitation, a lack of sustained apex argues against moderate to severe AR –LR =0.1 Frank, 1965.	1	2
	Palpable S4 / Apex not sustained -EF > 50% Palpable S4 / Apex sustained -EF 40-50% S4 not palpable / Apex sustained -EF < 40% Ranganathan, 1985.
	Double Apical Impulse	Anterior or apical ventricular aneurysms			Multiple studies McGee, 2007, Chapter 34.	1	2
	Retracting Apex	Constricture pericarditis and tricuspid regurgitation	Inward motion begins at s1 and does not return until after s2	90% of constrictive pericarditis Needs study	Boicourt, 1965. El Sherif, 1971.	1	1
	Heaves; lifts, thrusts	refers to sustained or hyperkinetic movements not at the apex; left parasternal heave refers to movement at the left 2nd - 4th interspace		Useful in specific situations such as suspected pulmonary hypertension. Different terms are confusing and should be avoided McGee, 2007, Chapter 34.	Left parasternal heave can discriminate those with RV pressures of >50mmHg +LR = 3.6, -LR = 0.4 Gillam, 1964. Right parasternal heave can indicate TR or MR Multiple studies McGee, 2007, Chapter 34.	1	2
Auscultation	Proper use of the stethoscope			Proper stethoscope use enhances hearing of heart sounds	Most important source of poor acoustic performance is air leak around ear piece. Rappaport, 1952. Diaphragm attenuates all sounds, therefore dropping low frequency sounds to below range of human hearing; Bell transmits all sounds well, allowing low frequency sounds through. Kindig, 1982.	2	4
	Examination in 3 different positions		Sitting Supine Left lateral decubitus	At least 3 positions are necessary to hear all relevant heart sounds	Sitting for splitting of s2, rubs and AR Left decubitus for detecting s3 and s4 and MS murmur McGee, 2007, Chapter 35.	1	4
	Order of Examination		Right upper sternal area; Entire left sternal border; Apex Using Bell and then diaphragm		No evidence	1	4
	Loud S1 Louder than S2 in aortic area	Mitral valve prolapse, mitral stenosis, left atrial myxoma			Tei, 1982. Perloff, 1962. Wood, 1954. Gershlick, 1984.	1	4
	Faint S1	MI, LBBB, long PR interval, acute AR		LV dysfuntion	McGee, 2007, Chapter 36.	1	4
	Variable S1	AV dissociation			In patients with pacer, variable S1 indicates AV dissociation +LR = 24.4 Meadows, 1963.	1	1
	Wide split S1	RBBB, LV ectopic beats				1	1
	Loud P2		Defined as either S2 heart better at left base than right base OR as S2 splitting with second sound louder		Studies do not support loud P2 as a sign of pulmonary hypertension	1	1
	Faint S2	AS		+LR = 3.1	Etchells, 1997.	1	1
	Wide split S2	RBBB, pulmonic stenosis, MR,				1	1
	Paradoxical splitting S2 Fixed split S2	LBBB, aortic stenosis, WPW with left accessory pathway LV dysfunction ASD, RV failure			Absence of fixed splitting argues against ASD in patients with wide split LR = 2.6 Perloff, 1958.	1	1
	S3	Rapid diastolic filling or LV dilatation, dysfunction and volume overload	Best heard over apex with bell if originating from left; best heard over left sternal border if coming from right ventricle McGee, 2007, Chapter 37.	S3 is worthwhile heart sound to look for	Detects EF < 50% +LR= 3.8 Detects EF < 30% +LR 4.1 Detects elevated left heart filling pressures +LR 5.7 Predicts post-op pulmonary edema +LR =14.6 Predicts post-op MI or cardiac death +LR = 8.0	1	3
	S4	Stiff ventricle	Best heard just medial to the apex with bell if originating from left; best heard over lower left sternal border if coming from right ventricle and is more obvious with inspiration McGee, 2007, Chapter 37.	More study is needed for s4's significance	Predicts 5 year mortality after MI +LR = 3.2 Does not reliably predict AS alone Aronow, 1982.	1	3
Murmurs	Presence or absence of murmurs				Cardiologists seem to be able to rule in abnormal systolic murmurs with fair degree of accuracy. Etchells, 1997. However Sapira suggests that this doesn’t mean it can’t be done.	1	3
	Intensity	Relates to whether a murmur is innocent or pathologic	Grade 1 to 6 as described by: Orient, 2005, p359.	Innocent murmurs are almost never grade 3 or more but pathologic murmurs can certainly be less than grade 3 Orient, 2005, p359.		1	2
	Location of maximal intensity	Relates to the origin of the murmur				1	2
	Radiation	Relates to the origin of the murmur				1	2
	Shape	Relates to the diagnosis of the murmur				1	2
	Timing	Systolic versus diastolic murmur	Early, mid, late systolic	Early or prolonged diastolic	See www.Blaufuss.org	1	3
Peripheral Exam
Examination of peripheral pulses	Inspection and palpation		Radial, brachial, carotid, femoral, popliteal, dorsalis pedis, posterior tibial pulses all can be palpated	the dorsalis pedis pulse is not palpable in 3 to 14% of people; posterior tibial pulse not palpable in up to 10% of the time HOWEVER only 0 to 2% have BOTH pulses absent pedal pulses	- absent posterior tibial and dorsalis pedis pulses 14.9; - LR = 0.3- absent femoral pulse + LR=6.1 McGee, 2007, Chapter 50.	1	2
	Auscultation		Carotid, subclavian, femoral, pulses could be auscultated for bruits	Bruits represent turbulent flow through a stenotic vessel	- limb bruit present +LR = 7.3; - LR = 0.3 Carter, 1981. Criqui, 1985.	1	2
Signs of arterial Insufficiency			Observation and palpitation of pallor, loss of hair, coolness, impaired nail growth, atrophic shinny skin appearance, arterial ulcers	- The most important signs are absence of both pedal pulses; the presence of any limb bruit; presence of sores, absence of femoral pulse, and asymmetrical coolness	- presence of sore on foot +LR = 7.0 - foot color abnormally blue, red or pale +LR-2.8; -LR=0.7 -atrophic skin +LR=2.7 -absent lower limb hair +LR =1.7 -foot asymmetrically cool +LR=6.1; - LR=0.9 McGee, 2007, Chapter 50.	1	2
	Capillary refill	This is a test of peripheral vascular disease and not a test of anemia	Multiple areas have been described from toe to index finger to thumb; duration of pressure is from 2 to 5 seconds; degree of pressure is not define; exact time of normal cap refill is from 2 to 5 seconds but may depend on age	Capillary refill time is a poor predictor of hemodynamic status in children Tibby, 1999. Lighting conditions may have a bearing on interpretation of cap refill Brown, 1994.	See excellent review by Ewan Kinnear at http://www.northampton.ac.uk/downloads/podiatry/ekdiss.pdf Cap refill time > 5 seconds +LR = 1.9 Boyko, 1997. Criqui, 1985. Lewis and Pickering both showed this is an unreliable sign McGee, 2007, Chapter 50.	4	4
	Ankle brachial index	Diminished blood flow to the lower limbs causes relative decrease in BP in the pedal pulses.	Highest systolic pressure at the Dosalis pedis and posterior tibial arteries with a handheld Doppler, divided by BP at the brachial artery (values > 0.92 are abnormal)	Check with thick cuff around calf and palpable at ankle.	Hiat, 1995.	1	2
	Buerger’s test		Elevate leg 90 degrees for 2 minutes, then dangle perpendicular to table edge for 2 minutes	A positive test is abnormal pallor with elevation and the appearance of dusky red flush spreading proximally from the toes in the dependent position		1	2
Signs of venous Insuffiency			Observation and palpation of rubor, purpura, warmness, edema, venous stasis ulcers			1	2
	Vein emptying time (venous filling)		Pick one vein on the leg while patient supine, elevate leg at 45 degrees for 1 minutes; the patient sits and dangles leg over exam table; record time it takes for vein to reappear	Times greater than 20 seconds are abnormal	+LR = 3.9 Boyko, 1997.	1	2

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AFMC National Clinical Skills Working Group Evidence-Based Clinical Skills Document

Table 6: Cardiovascular Exam