Physical Examination of the Cardiovascular System¶

Chapter 246 | Part 6: Disorders of the Cardiovascular System

KEY CLINICAL POINTS¶

Jugular Venous Pressure (JVP) measurement is critical for assessing right atrial pressure and detecting volume overload.
Cardiac murmurs are classified by timing (systolic, diastolic, continuous) and mechanism (valvular, obstructive, regurgitant).
Physical examination findings (e.g., pulsus paradoxus, Corrigan's pulse) provide essential clues for diagnosing conditions like pericardial tamponade or aortic regurgitation.
Dynamic maneuvers (Valsalva, squatting, passive leg raising) alter murmur intensity and help differentiate valvular vs. non-valvular causes.
Abnormal pulse characteristics (e.g., bisferiens pulse, pulsus alternans) correlate with specific pathologies like hypertrophic cardiomyopathy or severe heart failure.

1. DEFINITION & OVERVIEW¶

The cardiovascular physical examination assesses heart function, hemodynamics, and structural abnormalities through inspection, palpation, percussion, and auscultation. It complements history-taking to identify risk factors, signs of disease, and guide diagnostic imaging.

1.1 General Physical Examination¶

Assess patient appearance, skin color (cyanosis, pallor, jaundice), and peripheral signs (clubbing, telangiectasias). Measure height/weight, BMI, and waist circumference to predict cardiovascular risk. Evaluate mental status and systemic symptoms (e.g., dyspnea, syncope).

1.2 Cardiovascular Examination¶

Focus on JVP, arterial pulses, heart sounds, murmurs, and signs of heart failure (e.g., peripheral edema, S3 gallop). Use standardized techniques for accurate assessment of systolic/diastolic pressures and pulse characteristics.

2. EPIDEMIOLOGY¶

Cardiovascular disease remains the leading cause of mortality globally. Risk factors include hypertension, hyperlipidemia, diabetes, obesity, and smoking. Physical examination findings (e.g., elevated JVP, peripheral edema) correlate with increased risk of heart failure and CVD mortality.

3. ETIOLOGY & PATHOPHYSIOLOGY¶

Cardiovascular abnormalities arise from structural defects (valvular disease, congenital anomalies), hemodynamic changes (hypertension, heart failure), or systemic conditions (e.g., connective tissue disorders). Turbulent blood flow, pressure gradients, and valve dysfunction generate murmurs. JVP reflects right atrial pressure and venous return.

3.1 JVP Mechanics¶

JVP is influenced by right atrial pressure, venous compliance, and cardiac filling. Elevated JVP ( ≥ 10 mmHg) indicates volume overload, constrictive pericarditis, or right-sided heart failure.

3.2 Pulse Dynamics¶

Pulse characteristics (e.g., Corrigan's pulse, pulsus paradoxus) reflect arterial compliance, cardiac output, and vascular resistance. Abnormal pulses may indicate aortic regurgitation, heart failure, or peripheral artery disease.

4. CLINICAL FEATURES¶

Key findings include: 1) JVP elevation with right-sided heart failure, 2) Systolic murmurs (e.g., aortic stenosis, mitral regurgitation), 3) Diastolic murmurs (e.g., aortic regurgitation, mitral stenosis), 4) Abnormal heart sounds (S3, S4, split S2), 5) Peripheral edema, cyanosis, or clubbing.

5. DIFFERENTIAL DIAGNOSIS¶

For systolic murmurs: aortic stenosis vs. mitral regurgitation; for diastolic murmurs: aortic regurgitation vs. mitral stenosis. Consider congenital anomalies (e.g., ventricular septal defect), valvular disease, or hypertrophic cardiomyopathy.

6. INVESTIGATIONS & DIAGNOSIS¶

Physical examination findings guide diagnostic imaging (echocardiography, angiography) and lab tests (BNP, troponin). JVP measurement and pulse assessment are critical for staging heart failure and detecting volume overload.

6.1 JVP Measurement¶

Measure JVP in the sitting position with legs dangling. Normal JVP is ≤ 8-10 cm. Elevated JVP (>10 cm) suggests right-sided heart failure, constrictive pericarditis, or superior vena cava syndrome.

6.2 Arterial Pulse Assessment¶

Evaluate pulse amplitude, rhythm, and character. Bounding pulses (e.g., in aortic regurgitation) vs. weak pulses (e.g., in peripheral artery disease) guide differential diagnosis.

7. MANAGEMENT & TREATMENT¶

Management depends on underlying pathology: 1) Antihypertensives for hypertension, 2) Diuretics for heart failure, 3) Anticoagulation for atrial fibrillation, 4) Surgical repair for valvular disease. Physical examination findings (e.g., pulsus paradoxus) inform urgent interventions (e.g., pericardiocentesis).

8. PROGNOSIS & COMPLICATIONS¶

Elevated JVP and signs of heart failure (e.g., peripheral edema, S3 gallop) correlate with poor prognosis. Untreated valvular disease may lead to progressive heart failure, arrhythmias, or embolic events. Early detection via physical examination improves outcomes.

9. SPECIAL CONSIDERATIONS¶

In pregnancy, assess for signs of heart failure (e.g., dyspnea, peripheral edema) and avoid certain maneuvers (e.g., Valsalva). In elderly patients, consider age-related changes in pulse dynamics and comorbidities (e.g., aortic sclerosis).

10. KEY POINTS & CLINICAL PEARLS¶

1) JVP is the most important bedside measurement for estimating right atrial pressure. 2) Dynamic maneuvers (e.g., Valsalva, squatting) alter murmur intensity and help differentiate valvular vs. non-valvular causes. 3) Pulsus paradoxus >10 mmHg suggests pericardial tamponade or severe pulmonary embolism. 4) Continuous murmurs (e.g., PDA) require imaging for confirmation.

Table 246-1: Effects of Physiologic Interventions on Heart Murmurs and Sounds¶

Respiration	Valsalva Maneuver	Positional Changes	Exercise
Right-sided murmurs increase with inspiration; left-sided murmurs increase with expiration	Most murmurs decrease; HOCM murmur increases; MVP murmur lengthens	Standing: most murmurs diminish; squatting: murmurs increase	Murmurs of PS/MS/AR/MR/VSD increase with exercise
PES is exception; left-sided sounds louder during expiration	Right-sided murmurs return to baseline faster than left-sided	HOCM murmur becomes louder; MVP murmur lengthens	HOCM murmur decreases with maximal hand grip