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

Table 6: Cardiovascular Exam

Physical Sign / ManoeuvreSubsetsRationaleTechnique(s)InterpretationEvidencePre-ClerkshipClerkship
Peripheral cyanosisMultiple etiologiesHands and feetincreased extraction of O2 from blood at the peripheries Anemic patients would require more deoxyhemoglobin to have the same amount of cyanosis44
Central cyanosisMultiple etiologiesLips, oral mucosaBlood 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
PallorAnemiaConjunctival, nail beds, palm, conjunctival rim pallorPallor 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 outPalmar crease pallor

Pallor at multiple sites

Facial pallor in light skinned persons
+LR 3.8

Nail bed pallor +LR 1.8

Conjunctiva rim pallor

Nardone, 1990.
Gjorup, 1986.
EdemaSystemic versus regionalHigh systemic venous pressures, hypo-albuminemia, obstruction to venous flow, lymph-edema, vascular permeabilityPressure 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 secondsEdema 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.
ClubbingCyanotic heart disease, endocarditisSee resp sectionShould not be a routine part of a cardiac examConsists of less than 10% of all causes of clubbing

Dickinson, 1993.
Vital Signs
Blood pressureAuscultatory gap White coat effectIndirect sphygmo-manometerIdentify hypertensionHemmelgan, 2004.44
Pulsus ParadoxusA exaggerated increase in BP difference between inspiration and expiration; Multiple etiologies including cardiac tamponade, right ventricular infarction, asthma PE, and uncommonly constrictive pericarditisWhen 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 mmHgTamponade:
+LR = 5.9; -LR – 0.03

Severe Asthma;
+ LR = 2.7; - LR = 0.5
McGee, 2007, Chapter 13.24
Pulse Assessment
Pulse characterRegular versus irregular amplitude rateIntermittent ectopy,
pulsus altermans
Respiration RateCheyne Stokes respirationCHF versus neurological disordersPatients with Cheyne stokes respiration have lower cardiac outputs, higher wedge pressures, and short survival

McGee, 2007, Chapter 17.
Inspection of Neck Veins and Carotid PulseInferring the CVPMeasurement of the JVP is useful because it infers the CVP, which is equal to the right ventricular end diastolic pressureMethod 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.
Locating the top of the JVPUsing 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.
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.
What about JVP waveform?X' dominant normalCV wave in afib, TRBrisk X'/Y in tamponadeSee
Constant, 2003.
Kussmaul’s Sign

(paradoxical elevation of JVP inspiration)

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 inspirationLikely 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.

Dell’Italia, 1983; Lorell, 1979.

Right Ventricular MI:
Burdine, 1965.

Ducas, 1983.
Carotid upstrokeDelayed/anacrotic
volume =AR
Bifid AS/AR or IHSS
Carotid BruitDetection of atherosclerotic disease in the carotid arteryListen 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 performedCardiac sizePoor diagnostic utility and uncertain clinical significance+LR = 2.4 to 2.5;
-LR = 0.05 to 0.1

McGee, 2007, Chapter 33.
Palpation of the PrecordiumFour cardinal positionsThrills, palpable heart sounds and extra heart sounds such as s3 and s4.Aortic, pulmonary, tricuspid, and mitral areasUseful to rule out pulmonary hypertension in MSPalpable P2 argues for pulmonary hypertension in MS +LR = 3.6, -LR = 0.05

Whitaker, 1954.
Palpable S2Pulmonary hypertensionSee auscultation of loud s2Detects pulmonary pressures of >50mmHg in patients with MS +LR=3.6, -LR = 0.5

Size of apexLeft lateral decubitus position at 45 degrees, diameter of 4cm of moreThe 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.
Location of apex

12 cm from MSL/2.5-3 cm diameter
Point of maximal impulse does not relate to anatomical apex of heartSupine; 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
Amplitude of apexIncrease implies volume overload=AR, MR, VSDSubjective processIn 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.
Sustained ApexDetects left sided pressure or volume overload; aortic aneurysm; cardiomyopathy; pulmonary hypertensionSupine position; the distention of the precordium extends to S2 or beyondA 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.
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 ImpulseAnterior or apical ventricular aneurysms Multiple studies
McGee, 2007, Chapter 34.
Retracting ApexConstricture pericarditis and tricuspid regurgitationInward motion begins at s1 and does not return until after s290% of constrictive pericarditis

Needs study
Boicourt, 1965.

El Sherif, 1971.
Heaves; lifts, thrustsrefers to sustained or hyperkinetic movements not at the apex; left parasternal heave refers to movement at the left 2nd - 4th interspaceUseful 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.
AuscultationProper use of the stethoscopeProper stethoscope use enhances hearing of heart soundsMost 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.
Examination in 3 different positionsSitting


Left lateral decubitus
At least 3 positions are necessary to hear all relevant heart soundsSitting for splitting of s2, rubs and AR

Left decubitus for detecting s3 and s4 and MS murmur

McGee, 2007, Chapter 35.
Order of ExaminationRight upper sternal area; Entire left sternal border; Apex

Using Bell and then diaphragm
No evidence14
Loud S1

Louder than S2 in aortic area
Mitral valve prolapse, mitral stenosis, left atrial myxomaTei, 1982.
Perloff, 1962.
Wood, 1954.
Gershlick, 1984.
Faint S1MI, LBBB, long PR interval, acute ARLV dysfuntionMcGee, 2007, Chapter 36.14
Variable S1AV dissociationIn patients with pacer, variable S1 indicates AV dissociation +LR = 24.4

Meadows, 1963.
Wide split S1RBBB, LV ectopic beats11
Loud P2Defined as either S2 heart better at left base than right base OR as S2 splitting with second sound louderStudies do not support loud P2 as a sign of pulmonary hypertension11
Faint S2AS+LR = 3.1 Etchells, 1997.11
Wide split S2RBBB, pulmonic stenosis, MR, 11
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.
S3Rapid diastolic filling or LV dilatation, dysfunction and volume overloadBest 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 forDetects 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
S4Stiff ventricleBest 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 significancePredicts 5 year mortality after MI +LR = 3.2

Does not reliably predict AS alone
Aronow, 1982.
MurmursPresence or absence of murmursCardiologists 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.
IntensityRelates to whether a murmur is innocent or pathologicGrade 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.
Location of maximal intensityRelates to the origin of the murmur12
RadiationRelates to the origin of the murmur12
ShapeRelates to the diagnosis of the murmur12
TimingSystolic versus diastolic murmurEarly, mid, late systolicEarly or prolonged diastolicSee www.Blaufuss.org13
Peripheral Exam
Examination of peripheral pulsesInspection and palpationRadial, brachial, carotid, femoral, popliteal, dorsalis pedis, posterior tibial pulses all can be palpatedthe 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.
AuscultationCarotid, subclavian, femoral, pulses could be auscultated for bruitsBruits represent turbulent flow through a stenotic vessel- limb bruit present +LR = 7.3; - LR = 0.3

Carter, 1981.
Criqui, 1985.
Signs of arterial InsufficiencyObservation 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.
Capillary refillThis is a test of peripheral vascular disease and not a test of anemiaMultiple 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 ageCapillary 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

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.
Ankle brachial indexDiminished 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, 1995.12
Buerger’s testElevate leg 90 degrees for 2 minutes, then dangle perpendicular to table edge for 2 minutesA positive test is abnormal pallor with elevation and the appearance of dusky red flush spreading proximally from the toes in the dependent position12
Signs of venous InsuffiencyObservation and palpation of rubor, purpura, warmness, edema, venous stasis ulcers12
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 reappearTimes greater than 20 seconds are abnormal+LR = 3.9
Boyko, 1997.