Cardiovascular Examination Guide: Heart Assessment

Cardiovascular Examination Foundation

Thorough cardiovascular examination enables detection of cardiac pathology and hemodynamic changes. Understanding normal physiology and variations guides interpretation of abnormal findings. Systematic assessment improves diagnostic accuracy.

Cardiac Assessment Facts:

• Physical examination detects 85% of major cardiac abnormalities
• Heart murmur prevalence 25-40% in adults
• Most cardiac murmurs are benign (flow murmurs)
• S3 gallop highly specific for cardiac dysfunction
• Elevated JVP indicates right heart or volume overload

Inspection: Visual Assessment

Precordium Inspection

• Observe from side (tangential light may reveal pulsations)
• Note visible apical impulse location
• Assess for heaves (hyperdynamic impulse)
• Look for scars (prior cardiac surgery)

General Appearance Signs

• Cyanosis: Central (lips, tongue) vs peripheral (fingers)
• Edema: Peripheral (feet, sacrum) suggesting right heart failure
• Clubbing: Fingers (chronic hypoxia from cardiac disease)
• Xanthomas: Cholesterol deposits (familial hyperlipidemia, CAD risk)

Palpation: Tactile Assessment

Apical Impulse Assessment

• Normal location: 5th intercostal space, midclavicular line
• Normal size: 1-2 cm diameter
• Palpability: Felt only one intercostal space above, 1-2 cm medial
• Displaced apical impulse: Suggests cardiomegaly or dilation
• Hyperkinetic impulse: Hyperdynamic heart (anemia, fever, hyperthyroidism)

Palpable Thrills

• Palpable murmurs (vibrations felt on chest wall)
• Systolic thrill: Aortic stenosis, hypertrophic cardiomyopathy
• Diastolic thrill: Mitral stenosis
• Continuous thrill: Patent ductus arteriosus

Heaves and Lifts

• Heave: Hyperdynamic impulse (left ventricle pressure overload)
• Right ventricular lift: Palpable at left lower sternal border (RV hypertrophy)
• Parasternal impulse: Indicates atrial enlargement

Heart Sounds: Interpretation and Abnormalities

Normal Heart Sounds

S1 (First Heart Sound)

• Origin: Mitral and tricuspid valve closure
• Timing: Beginning of systole
• Location: Heard best at apex
• Pitch: Low-pitched, "Lub"
• Components: May be split (two components heard separately)

S2 (Second Heart Sound)

• Origin: Aortic and pulmonic valve closure
• Timing: End of systole (beginning of diastole)
• Location: Heard best at left sternal border and aortic area
• Pitch: High-pitched, "Dub"
• Physiologic split: Normal splitting with inspiration (increases RV stroke volume)

Abnormal Extra Sounds

S3 Gallop (Ventricular Gallop)

• Timing: Early diastole (after S2)
• Cause: Rapid ventricular filling
• Abnormality: Indicates heart failure, ventricular dysfunction
• Associated: Usually with dilation and elevated filling pressures
• Significance: Highly specific for cardiac dysfunction

S4 Gallop (Atrial Gallop)

• Timing: Late diastole (before S1)
• Cause: Forceful atrial contraction against stiff ventricle
• Abnormality: Indicates diastolic dysfunction
• Associated: Hypertension, hypertrophic cardiomyopathy, myocardial infarction
• Sound: "Ken-tuck-ee" with S3, sounds like gallop rhythm

Cardiac Murmurs: Characterization and Significance

Murmur Characteristics (SCALE)

• Systolic (S): Occurs between S1 and S2
• Configuration (C): Crescendo-decrescendo, holosystolic, or other pattern
• Area (A): Where heard best (aortic, mitral, pulmonary, tricuspid)
• Loudness (L): Grade I-VI (I=barely audible, VI=palpable thrill without stethoscope)
• Extras (E): Associated clicks, splits, other findings

Systolic Murmurs (Heard Between S1 and S2)

Aortic Stenosis

• Crescendo-decrescendo pattern
• Heard best at right sternal border
• Radiates to neck/carotids
• Associated with ejection click

Mitral Regurgitation

• Holosystolic (throughout systole)
• Heard best at apex
• Radiates to left axilla
• High-pitched "blowing" quality

Ventricular Septal Defect

• Holosystolic murmur
• Heard best at left lower sternal border
• Associated with thrill

Diastolic Murmurs (Heard Between S2 and S1)

Aortic Regurgitation

• Early diastolic, high-pitched, "blowing"
• Heard best at left sternal border (patient sits forward)
• Long murmur indicates severe regurgitation

Mitral Stenosis

• Mid-diastolic rumble
• Heard best at apex (use bell of stethoscope)
• Associated with opening snap
• Louder with patient in left lateral decubitus

Continuous Murmurs

• Patent ductus arteriosus: "Machine-like" murmur
• Continuous throughout systole and diastole
• Associated with bounding pulses

Carotid and Jugular Venous Assessment

Carotid Pulse Characteristics

• Assess amplitude and upstroke (rapid vs slow)
• Brisk upstroke: Normal or aortic regurgitation
• Slow upstroke: Aortic stenosis
• Bisferi ens (double peak): Hypertrophic cardiomyopathy
• Asymmetry: Suggests arterial stenosis

Jugular Venous Pressure (JVP)

• Normal JVP: <4 cm H2O above sternal angle
• Elevated JVP: Suggests right heart failure, volume overload
• Assessment: Patient at 45-degree angle, measure vertical distance
• Hepatojugular reflux: Further rise with liver pressure suggests right heart failure

Peripheral Vascular Assessment

Pulse Assessment

• Palpate radial, femoral, popliteal, dorsalis pedis, posterior tibial
• Rate: Normal 60-100 bpm
• Rhythm: Regular or irregular
• Amplitude: Full or weak
• Compare bilateral sides (asymmetry suggests stenosis)

Extremity Assessment

• Color: Pink or pale/cyanotic
• Temperature: Warm or cold (ischemia)
• Edema: Dependent edema suggests right heart failure
• Skin changes: Shiny, hairless suggests chronic ischemia
• Ulcers: Venous or arterial (location and characteristics differ)

Key Takeaways: Cardiovascular Mastery

• Perform systematic cardiovascular assessment every visit
• Locate and characterize apical impulse
• Identify normal vs abnormal heart sounds
• Characterize murmurs using SCALE framework
• Assess carotid pulses and aortic integrity
• Measure and interpret jugular venous pressure
• Evaluate peripheral pulses bilaterally
• Correlate findings with patient symptoms and diagnosis