7 Physical Examination of the Heart and Circulation
Total Page：16
File Type：pdf, Size：1020Kb
Chapter 7 / Physical Examination of the Heart and Circulation 99 7 Physical Examination of the Heart and Circulation Jonathan Abrams, MD CARDIAC EXAMINATION The examination of the heart and circulation has a long and rich tradition in clinical medicine. Most of the cardinal signs of cardiovascular disease detectable on the physical examination were described and documented by master physicians during the 19th and early 20th centuries. Subse- quently, echocardiography and cardiac catheterization have demonstrated that the presumed patho- genesis of many to most cardiovascular abnormalities on the physical examination were accurately and presciently described before these modern techniques became available. In the past, genera- tions of internists and cardiologists were well trained in the skills of cardiac examination; the absence of our current ultrasound technology providing “immediate” answers contributed to the emphasis of expertise in cardiac physical diagnosis. Unfortunately, clinical skills in this area are no longer emphasized in medical education, in part due to the burgeoning of other aspects of medical science that must be taught in the medical student curriculum. The advent of readily available two-dimen- sional echocardiography has clearly contributed to the demise of cardiac physical diagnosis capabil- ity among physicians, a phenomenon well documented in recent published studies. This chapter will highlight the core components of the cardiac physical examination, and will focus on a practical assessment of the heart and circulation in health and disease. The author’s assumption is that the reader will already possess a basic knowledge of one cardiac exam and struc- tural heart disease. It is hoped that physicians will redouble their efforts in applying the well-known components of the cardiac examination to their patients. The rewards are many—in particular, a feeling of real satisfaction in making a diagnosis of organic heart disease with one’s hands and ears. Limitation of the Cardiac Examination Echocardiography has clearly demonstrated that much cardiovascular disease is not detectable or accurately quantifiable, even to the expert, on the physical examination. For instance, mitral and aortic regurgitation are often missed; left ventricular function may be significantly depressed with- out a detectable abnormality on examination. Thus, it is best to consider the physical examination and the echo as complementary. For the experienced clinician, the findings on the cardiac exam often predict what will be noted on the echo. Nevertheless, if significant heart disease is suspected, a complete 2-D echo-Doppler examination is often indicated. Conversely, with a negative cardiac physical examination in the setting of a normal electrocardiogram, an echo can be avoided in many instances. The Cardiac Exam The components of the cardiac physical examination are standard (Table 1). As with the more general physical examination, physicians are urged to conduct the cardiac exam in a systematic From: Essential Cardiology: Principles and Practice, 2nd Ed. Edited by: C. Rosendorff © Humana Press Inc., Totowa, NJ 99 100 Abrams Table 1 Cardiac Pysical Examination Overall assessment of the patient General features, e.g., dyspnea, cyanosis, edema Special features, e.g., unusual facies, lipid deposits Blood pressure Supine, upright Leg pressure (if coarctation suspected) Arterial pulses Contour, volume Precordial motion LV apex impulse (PMI) RV activity Ectopic impulses Thrills (loud murmur) Heart Sounds Characteristics of S1, S2 Is an S3 or S4 present? Ejection or nonejection clicks Opening snap Heart Murmurs Systolic Diastolic Continuous Timing in cardiac cycle Quality Length Radiation Table 2 Blood Pressure and Peripheral Arterial Examination Clues to Cardiovascular Disease Coarctation of aorta Hypertension in upper extremities; brachial–femoral delay Aortic regurgitation Wide pulse pressure with increased systolic and decreased diastolic pressure Increased volume, rate of rise of arterial pulses with exaggerated collapse Pulsus or mechanical Beat-to-to beat alternation in peak pressure and pulse volume (detect by alternans palpation, not cuff) Pulsus paradoxus Exaggerated inspiratory decline (>10 mmHg) in peak systolic pressure measured carefully by cuff; palpation may pick up if severe Hypertension Elevated systolic and diastolic pressure; increased systolic pressure with normal diastolic (isolated systolic hypertension of the elderly) and sequential fashion. After a general assessment of the patient, the arterial pulses and pressure and venous pulsations are evaluated, followed by careful inspection and palpation of the precordium. Auscultation is the last but most important component of the cardiac exam. EVALUATION OF ARTERIAL PULSE An accurate determination of arterial pressure is part of the cardiac physical examination. Careful attention to the details of the technique of taking blood pressure are important. Abnormali- ties of blood pressure are not usually a component of structural heart disease except in selected instances (Table 2). Assessment of the severity of aortic regurgitation or detection of pulsus para- doxus are two situations in which the blood pressure can provide important information. Chapter 7 / Physical Examination of the Heart and Circulation 101 Fig. 1. The arterial pulse in aortic stenosis. Note the delayed upstroke and the jagged contour representing a palpable shudder or transmitted thrill. The pulse volume is usually decreased as well. The Examination The physician must become familiar with the normal volume and rate of rise of the arterial pulse. In general, the carotid artery is the only artery that should be utilized for detection of cardio- vascular abnormalities. Because of delay of transmission of the pulse wave in the periphery, as well as the distal decrease in arterial diameter, assessment of the radial or brachial arterial pulses usually is of little value (except in the assessment of pulsus alternans, pulsus paradoxus, and cardiogenic shock). In hypertensive patients, simultaneous assessment of the brachial and femoral arterial pulses is useful to rule out a significant coarctation of the aorta. In such cases, the femoral peak of the pulse wave peak will clearly follow the palpable brachial artery impulse; a delay indicates a probable obstruction in the aorta. The contour of the aortic pulse is important in the assessment of aortic valve disease. Aortic stenosis characteristically produces a small volume, late peaking, or delayed carotid upstroke, often with a palpable shudder or thrill (anacrotic notch, transmitted murmur) (see Fig. 1). Remember that in the healthy older subject, decreased compliance and increased arterial stiffness typically result in an increase in the arterial pulse amplitude as well as the pulse pressure. This can readily mask the typical abnormalities of aortic stenosis. Aortic regurgitation, when significant (e.g., 2+/4), typically results in an arterial pulse with an increased amplitude and rate of rise and a collapsing quality. In severe aortic regurgitation, the aortic pulsations are abnormal throughout the arterial system (see Table 3). A prominent (often visible), high-amplitude, full-volume carotid arterial pulse, coupled with a wide pulse pressure (diastolic blood pressure 60 mmHg) is highly suggestive of severe aortic regurgitation. A double peaking or bisferiens pulse is common in advanced aortic regurgitation (Fig. 2). PULSUS PARADOXUS A greater-than-normal difference in systolic blood pressure between inspiration and expiration is known as pulsus paradoxus. This is common whenever there are major fluctuations of intratho- racic pressure or in pericardial tamponade. Careful palpation and auscultation is mandatory to detect significant pulsus paradoxus (>10 mmHg). Normally, there is a slight physiologic respira- tory difference between inspiration and expiration, typically 6 to 8 mmHg or less during quiet respiration. Pulsus paradoxus may be detected in severe congestive heart failure, decompensated chronic obstructive lung disease, asthma, and in an occasional very obese individual. PULSUS ALTERNANS In setting of severe left ventricular systolic dysfunction, beat-to-beat alteration in the peak amplitude of the arterial pulse may be noted (Fig. 3). This can be palpated in the brachial or radial 102 Abrams Table 3 Peripheral or Nonauscultatory Signs of Severe Aortic Regurgitation: A Glossary Bisferiens pulse A double or bifid systolic impulse felt in the carotid arterial pulse. Corrigan’s sign Visible pulsations of the supraclavicular and carotid arteries. Pistol shot of Traube A loud systolic sound heard with the stethoscope lightly placed over a femoral artery. Palmar click A palpable, abrupt flushing of the palms in systole. Quincke’s pulse Exaggerated sequential reddening and blanching of the fingernail beds when light pressure is applied to the tip of the fingernail. A similar effect can be induced by pressing a glass slide to the lips. Duroziez’s sign A to-and-fro bruit heard over the femoral artery when light pressure is applied to the artery by the edge of the stethoscope head. This bruit is caused by the exaggerated reversal of flow in diastole. DeMusset’s sign Visible oscillation or bobbing of the head with each heartbeat. Hill’s sign Abnormal accentuation of leg systolic blood pressure, with popliteal pressure 40 mmHg or higher than brachial artery pressure. Water-hammer pulse The high-amplitude, abruptly collapsing pulse of aortic regurgitation.