1440 1441 ## Functional Capacity 1442 1443 Assessment of functional capacity should be documented for management and follow-up purposes. The Canadian Cardiovascular Society10 (Table 2–2) and the New York Heart Association11 scales (Table 2–3) are widely used tools. In our experience, even a simple 1 (bedridden) to 10 (no physical limitations) Likert scale is helpful in the longitudinal assessment of patients and tends to correlate well with objective exercise capacity (exercise maximal oxygen consumption). In some diseases, there is such a gradual hemodynamic impairment that patients may not perceive a functional limitation; they will slowly decrease their activity level. Information obtained from a spouse or other close observer regarding activity level over the years may be of value. 1444 1445 *TABLE 2–3. New York Heart Association Functional Classification* 1446 1447 1448

Class I	No limitation of physical activity; physical activity does not cause fatigue, palpitation, dyspnea, or angina
Class II	Slight limitation of ordinary activities; comfortable at rest; ordinary physical activity results in fatigue, palpitation, dyspnea, or angina
Class III	Marked limitations of physical activity; comfortable at rest; less than ordinary activities causes fatigue, dyspnea, or angina
Class IV	Inability to carry on any physical activity without symptoms; symptoms of heart failure of anginal might be present at rest If any activity is undertaken, discomfort is increased

1449 1450 With the aging population, it is important to assess the presence and extent of frailty in patients being considered for interventions. Frailty indices have been shown to be predictive of survival in this population.12 The ability to perform activities of daily living is a necessary component of the frailty assessment. The degree of independence and interaction with family will be useful information for decision-making regarding interventions in the older frail patient. 1451 1452 1453 ## PHYSICAL EXAMINATION: INSPECTION, blood pressure, and palpation 1454 1455 1456 ## General Examination and Inspection 1457 1458 A thorough general examination, including a funduscopic examination, should always be performed and signs of other comorbidities (such as cirrhosis, obstructive lung disease, or stroke) should be sought. Attention to the patient's dentition is of major importance, in particular, in patients with valve disease or for those undergoing preoperative evaluation. Visible pulsa- tions should be noted, with respect to location and origin (arte- rial vs venous). Details regarding the noncardiovascular and eye examinations are, however, beyond the scope of this chapter. 1459 1460 Our patient population is aging, and frailty assessment should also be included as part of the physical examination. Gait speed (15-foot walk), handgrip strength, and muscle wasting should be recorded; multiple scores13,14 have also been developed. This assessment should be a standard part of clinical evaluation and should be performed in patients undergoing catheter-based interventions or surgical treatment. 1461 1462 Several syndromes have been associated with cardiovascular disease, including aortopathies, hypertrophic cardiomyopathy, congenital heart disease, and even cardiac tumors. Careful inspection of the facies, body habitus, and extremities is neces- sary in order to suspect the presence of a syndrome. Although these syndromes are rare, their identification can lead to the initial suspicion of the cardiac diagnosis, which may have life-saving implications for patients and their families. Some of those findings are illustrated in the Table 2–4. 1463 1464 1465 ## Blood Pressure Measurement 1466 1467 1468 ## Blood Pressure: Technique 1469 1470 Although vital signs are frequently recorded by the ancillary staff prior to the encounter with the provider, we recommend that the measurements be repeated during physical examination by the clinician. This prevents abnormalities from being "missed" due to time constraints and also forces the examiner to certify that all the necessary steps for the measurement of blood pressure have been done (eg, that both arms are checked); this is particularly important during the patient's initial evaluation. [... Output truncated due to length. 5429 tokens/22012 characters removed ...]