Complete Cardiovascular System Examination

I. GENERAL INSPECTION (Before Touching the Patient)

• Malar flush (mitral stenosis)
• Marfanoid habitus (tall, long extremities, pectus excavatum/carinatum - aortic root disease, MVP)
• Down syndrome (AV canal, VSD, ASD)
• Turner syndrome (coarctation of aorta, bicuspid aortic valve)
• Noonan syndrome (pulmonary stenosis, HCM)
• Acromegaly (cardiomegaly, hypertension)
• Cushing syndrome (hypertension, cardiomegaly)

• Central cyanosis: bluish discoloration of lips/tongue - right-to-left shunts, severe pulmonary disease
• Peripheral cyanosis: fingertips/toes - reduced peripheral circulation
• Clubbing: infective endocarditis, cyanotic congenital heart disease, Eisenmenger syndrome
• Splinter haemorrhages (infective endocarditis)
• Janeway lesions (painless palmar/plantar embolic lesions - infective endocarditis)
• Osler nodes (painful nodules on fingertips - infective endocarditis)
• Xanthelasma and tendon xanthomata (hypercholesterolaemia, premature atherosclerosis)
• Arcus senilis (significant if <45 years)
• Koilonychia (iron-deficiency anaemia causing high-output state)

• Dyspnoea at rest, tachypnoea
• Cheyne-Stokes breathing (severe LV failure)

II. BLOOD PRESSURE

• Patient seated, arm at heart level, feet on floor, back supported; 5-10 min rest
• Cuff bladder: length 80%, width 40% of arm circumference
• Inflate 30 mmHg above expected systolic; deflate at 2-3 mmHg/s
• Systolic = Phase I Korotkoff sound; Diastolic = Phase V (disappearance); record both Phase IV and Phase V when diastolic near zero (severe AR, large AV fistula)

III. ARTERIAL PULSE EXAMINATION

Pulse Characters and Their Clinical Significance

IV. JUGULAR VENOUS PRESSURE AND WAVEFORM

Patient Positioning

• Begin in semi-recumbent position (30-45°)
• Examine the internal jugular vein (preferred - directly in line with SVC and right atrium; the external jugular is valved)
• Measure the vertical height of venous pulsation above the sternal angle (angle of Louis); >4.5 cm at 30-45° is abnormal
• The sternal angle reference underestimates CVP - use it to distinguish normal from elevated rather than to quantify precisely
• Alternatively, pulsations above the clavicle in the sitting position are clearly abnormal (clavicle-to-RA distance >10 cm)
• Convert cmH₂O to mmHg: 1.36 cmH₂O = 1.0 mmHg

Differentiating JVP from Carotid Pulse

• Venous pulsation is non-palpable (easily obliterated by light pressure); carotid is palpable
• JVP is usually biphasic (in sinus rhythm); carotid is monophasic
• JVP changes with posture and inspiration; carotid does not
• JVP can be abolished by pressing below the jaw

The JVP Waveform Components

Abnormalities of Each Component

• Large (prominent) a wave: reduced RV compliance (pulmonary hypertension, pulmonary stenosis, tricuspid stenosis)
• Cannon a wave: AV dissociation - RA contracts against closed tricuspid valve (VT diagnosis clue!)
• Absent a wave: atrial fibrillation

• Blunted/absent: atrial fibrillation (no atrial relaxation), tricuspid regurgitation (replaced by v wave)
• Deep x descent: constrictive pericarditis (enhanced annular descent + preserved atrial relaxation)

• Large v wave (CV wave = ventricularization): severe tricuspid regurgitation - regurgitant volume raises RA pressure throughout systole; in extreme cases, single large positive systolic wave

• Rapid, prominent y descent: tricuspid regurgitation, constrictive pericarditis, restrictive cardiomyopathy (rapid early RV filling)
• Blunted/absent y descent: cardiac tamponade (elevated pericardial pressure prevents early diastolic RV filling), tricuspid stenosis

V. PRECORDIAL EXAMINATION

1. Inspection

• Scars: median sternotomy (previous cardiac surgery), lateral thoracotomy
• Visible apex beat (normally 5th ICS, midclavicular line)
• Visible pulsation at left sternal border (RV heave), upper left sternal border (pulmonary artery dilation in pulmonary hypertension), right parasternal (aortic aneurysm)
• Chest deformities: pectus excavatum (Marfan, MVP), pigeon chest

2. Palpation

• Normal: 5th intercostal space, just medial to the midclavicular line; brief, non-sustained tap
• Displaced laterally and/or downward: LV dilatation (volume overload - MR, AR, DCM)
• Sustained/heaving impulse: LV hypertrophy (pressure overload - AS, hypertension)
• Double impulse (bifid apex): HOCM (palpable S4 + systolic impulse), severe MR
• Tapping apex: palpable S1 (mitral stenosis)
• Hyperdynamic apex: high-output states, volume overload

• Place heel of hand at left sternal border (3rd-4th ICS)
• RV heave/lift = sustained outward thrust: RV hypertrophy or dilatation (pulmonary hypertension, pulmonary stenosis, severe MR with enlarged right heart)

• Palpable P2 = pulmonary hypertension
• Diastolic shock in pulmonary hypertension

• 2nd right ICS: AS, aortic sclerosis
• 2nd left ICS: pulmonary stenosis
• Lower left sternal border: VSD
• Apex: MR, MS (diastolic thrill)

3. Percussion

VI. AUSCULTATION

Technique

• Aortic area: 2nd right ICS
• Pulmonary area: 2nd left ICS
• Tricuspid area: Lower left sternal border / xiphoid
• Mitral area (apex): 5th ICS, MCL

• Supine: baseline assessment
• Left lateral decubitus: brings LV apex closer to chest wall; enhances S3, S4, and MS rumble
• Sitting forward, breath held in expiration: brings aortic valve close; enhances AR diastolic murmur and pericardial rub

Heart Sounds

S1 (First Heart Sound)

• Produced by closure of mitral (M1) and tricuspid (T1) valves
• M1 precedes T1; normally heard as a single sound at apex
• Best heard: apex with diaphragm

• Loud S1: mitral stenosis (mobile leaflets), short PR interval, high cardiac output states
• Soft S1: calcified/immobile mitral leaflets (advanced MS), long PR interval (1st degree AV block), severe MR (early valve closure), LV systolic dysfunction
• Variable S1: complete heart block (PR interval changes beat-to-beat), AF

S2 (Second Heart Sound)

• Produced by closure of aortic (A2) and pulmonary (P2) valves
• A2 normally precedes P2; best heard at base (2nd ICS)
• P2 normally audible only at 2nd left ICS; if heard at apex or widely - pulmonary hypertension

• Physiological splitting: normal with inspiration (increased RV stroke volume delays P2); disappears on expiration
• Wide fixed splitting: ASD (constant volume overload of right heart)
• Wide splitting (not fixed): RBBB, pulmonary stenosis, MR (early A2 from reduced LV output), VSD
• Paradoxical (reversed) splitting: A2 comes after P2; heard in expiration, disappears with inspiration. Causes: LBBB, severe AS (delayed A2), HOCM, RV pacing, PDA

• Loud P2: pulmonary hypertension
• Soft P2: severe pulmonary stenosis (immobile valve)
• A2-P2 interval inversely proportional to severity of pulmonary hypertension (narrower with increasing PHTN)

S3 (Third Heart Sound)

• Low-pitched, heard in early diastole during rapid ventricular filling phase
• Best heard: LV apex, with bell, left lateral decubitus
• Rhythm: "Ken-tuc-ky"
• Normal: children, young adults, athletes, pregnancy (physiological)
• Pathological: heart failure (predicts HF morbidity/mortality), dilated cardiomyopathy, volume overload (MR, AR)
• Right-sided S3: lower left sternal border, louder with inspiration; seen in severe RV dysfunction, severe TR
• S3 equally prevalent in HFpEF and HFrEF

S4 (Fourth Heart Sound)

• Low-pitched, heard in late diastole (atrial filling phase) - presystolic
• Best heard: LV apex with bell
• Rhythm: "Ten-nes-see"
• Indicates reduced ventricular compliance; LV presystolic expansion
• Causes: LV hypertrophy (hypertension, AS, HOCM), active myocardial ischemia/infarction, hypertrophic cardiomyopathy
• Absent with: atrial fibrillation (no active atrial contraction)
• Right-sided S4: louder with inspiration; pulmonary hypertension, pulmonary stenosis

Gallop Rhythms

• S3 gallop: tachycardia + S3 (heart failure)
• S4 gallop: tachycardia + S4 (ischemia, hypertrophy)
• Summation gallop: tachycardia with both S3 + S4 occurring simultaneously (fast heart rate merges them); analogous to fused E+A waves on echo Doppler

Opening Snap (OS) - Mitral Stenosis

• High-pitched, early diastolic sound; heard after S2
• Heard best: lower left sternal border and apex; wide radiation (can be heard at aortic area)
• Distinguished from S3: OS is high-pitched (unlike low-pitched S3); louder with diaphragm; heard at sternal border not just apex
• A2-OS interval: inversely proportional to LA-LV diastolic pressure gradient and severity of MS
  • Short A2-OS (<70 ms): severe MS (elevated LA pressure, early MV opening)
  • Long A2-OS (>100 ms): mild MS
• Crisp/loud OS: mobile, pliable leaflets - amenable to balloon valvuloplasty
• Soft/absent OS: calcified, immobile leaflets - not suitable for valvuloplasty

Pericardial Knock

• High-pitched early diastolic sound, slightly later than OS
• Corresponds to abrupt cessation of ventricular expansion after tricuspid valve opening
• Associated with prominent rapid y descent on JVP
• Constrictive pericarditis

Tumor Plop

• Lower-pitched diastolic sound; atrial myxoma prolapsing across mitral valve
• Position-dependent

Ejection Sounds (Clicks)

• High-pitched, early systolic, corresponds to upstroke of carotid pulse
• Aortic ejection sound: bicuspid aortic valve, aortic root dilation; becomes softer as valve calcifies
• Pulmonary ejection sound: pulmonary valve stenosis, pulmonary root dilation
  • Only right-sided acoustic event that decreases with inspiration
  • Moves closer to S1 as PS severity increases
• Both heard best at lower left sternal border, not just the base

Non-Ejection Click (Mid-Systolic Click) - Mitral Valve Prolapse

• High-pitched click after carotid upstroke
• May be single or multiple; may introduce a late systolic murmur
• Moves toward S2 (away from S1) with maneuvers that increase LV preload (squatting)
• Moves toward S1 with maneuvers that decrease preload (standing, Valsalva)

Heart Murmurs

Systolic Murmurs

• Start immediately at S1 (at mitral valve closure) and extend to S2
• High-pitched, plateau (constant intensity), harsh or blowing quality
• Mechanism: pressure gradient from ventricle to atrium (or VSD) throughout entire systole
• Mitral regurgitation (MR): best at apex; radiation to axilla (anteriorly directed jet from posterior leaflet prolapse radiates to base; posteriorly directed jet from anterior leaflet prolapse radiates to back/spine)
• Tricuspid regurgitation (TR): lower left sternal border; louder with inspiration (Carvallo's sign)
• VSD: lower left sternal border; may be associated with thrill

• Start after S1 (after semilunar valve opens = end of isovolumetric contraction), end before or at S2
• Crescendo-decrescendo (diamond-shaped) configuration; harsh quality
• Aortic stenosis (AS): 2nd right ICS; radiates to carotids and apex; late-peaking, harsh
  • Severe AS: parvus et tardus carotid upstroke, late-peaking Grade ≥3, soft A2, sustained LV impulse, S4
• Pulmonary stenosis (PS): 2nd left ICS; preceded by ejection click; radiates to left shoulder
• HOCM: lower left sternal border/apex; Brockenbrough sign; responds dramatically to bedside maneuvers (see below)
• ASD: pulmonary area; due to increased pulmonary flow (not the defect itself); fixed split S2
• Flow murmurs: fever, anemia, thyrotoxicosis, pregnancy, high-output states

• Begin in mid-late systole; introduced by non-ejection click
• MVP: click + late systolic murmur; apex + left sternal border

Diastolic Murmurs

• Begin immediately at S2; high-pitched; best heard with diaphragm
• Aortic regurgitation (AR): 3rd left ICS (left sternal border); best heard sitting forward, breath held in expiration; radiation to apex; Austin Flint murmur (low-pitched mid-diastolic rumble at apex due to AR jet hitting mitral leaflet)
• Pulmonary regurgitation: 2nd left ICS; Graham Steell murmur (high-pressure PR in pulmonary hypertension)

• Mitral stenosis: apex; low-pitched, rumbling; best heard with bell, left lateral decubitus; preceded by OS; presystolic accentuation in sinus rhythm (absent in AF); louder after exercise
• Tricuspid stenosis: lower left sternal border; louder with inspiration; preceded by OS

Continuous Murmurs

• Heard in both systole and diastole, peak around S2
• Patent ductus arteriosus (PDA): 2nd left ICS; "machinery" murmur
• Arteriovenous fistula; coronary arteriovenous fistula; rupture of sinus of Valsalva aneurysm

Bedside Maneuvers to Identify Murmurs

Pericardial Friction Rub

• Scratching, leathery, superficial sound with up to 3 components (atrial systole, ventricular systole, early diastole)
• Best heard: sitting forward, breath held in expiration, diaphragm pressed firmly
• Variable from examination to examination
• Present in acute pericarditis, post-MI (Dressler syndrome), post-cardiac surgery, uraemia

VII. PERIPHERAL EXAMINATION

Lower Limbs

• Oedema: pitting bilateral ankle/leg oedema; if JVP elevated = volume overload (CHF, constrictive pericarditis); if JVP normal = hypoalbuminaemia, venous insufficiency, CCB (dihydropyridine) side effect, lymphoedema
• Venous signs: varicosities, venous ulcers (medial, with brown hemosiderin discolouration - "eburnation")
• Arterial signs: pallor, cool skin, hair loss, muscular atrophy, absent pulses (peripheral arterial disease)
• Homans sign: posterior calf pain on active dorsiflexion against resistance for DVT - neither specific nor sensitive; should not be relied upon

Hepatomegaly

• Tender hepatomegaly = acute hepatic congestion from right heart failure
• Pulsatile liver = severe tricuspid regurgitation
• Systolic hepatic pulsation corresponds to regurgitant v waves

Splenomegaly

• Infective endocarditis (septic emboli)

VIII. SPECIAL SIGNS OF SYSTEMIC DISEASE AFFECTING THE HEART

IX. SYSTEMATIC ORDER OF CARDIOVASCULAR EXAMINATION (as per Hutchinson's Scheme)

1. General inspection - position, distress, dyspnoea, body habitus, skin, face
2. Hands - clubbing, cyanosis, peripheral signs of endocarditis, temperature, radial pulse
3. Arms - blood pressure (both arms), brachial pulse
4. Face/Eyes - xanthelasma, corneal arcus, conjunctival pallor/petechiae (anaemia, endocarditis), Roth spots, malar flush, cyanosis of lips, dental hygiene
5. Neck - JVP (height and waveform), carotid pulse (character), carotid bruits
6. Chest inspection - shape, scars, apex beat visibility, visible pulsations
7. Palpation - apex beat (position, character), left sternal border heave, thrills, palpable P2
8. Auscultation - systematic across all areas, appropriate positions, maneuvers as indicated
9. Back - sacral oedema (bedridden), bibasal crepitations (pulmonary oedema), pleural effusion (dullness)
10. Abdomen - hepatomegaly (size, tenderness, pulsatility), splenomegaly, ascites, abdominal aorta palpation and auscultation, renal bruits
11. Lower limbs - femoral/popliteal/pedal pulses, femoral bruits, ankle/leg oedema, venous/arterial signs
12. Fundoscopy - hypertensive/diabetic retinopathy, Roth spots
13. Temperature/other vitals as indicated

Summary of Key Clinical Correlations