Signs of Heart Disease
Although the cardiovascular examination centers on the heart, peripheral signs
often provide important information.
Appearance
Although cardiac patients may appear healthy and
comfortable at rest, many with acute myocardial infarction appear anxious and
restless. Diaphoresis suggests hypotension or a hyperadrenergic state,
such as during pericardial tamponade, tachyarrhythmias, or myocardial
infarction. Cold and clammy skin or pallor suggests low cardiac output and may
be a sign of cardiogenic shock or anemia. Patients with severe chronic CHF or
other long-standing low cardiac output states may appear cachectic.
Cyanosis may be central, due to arterial
desaturation, or peripheral, reflecting impaired tissue delivery of adequately
saturated blood in low-output states, polycythemia, or peripheral
vasoconstriction. Clubbing may be present in chronic cyanotic states. Central
cyanosis may be caused by pulmonary disease, left heart failure, or
right-to-left intracardiac or intrapulmonary shunting; the latter will not be
improved by increasing the inspired oxygen concentration. Edema may be present
and its pitting nature and extent quantified. Note if presacral edema is
present. Severe right heart failure may also present with ascites and scrotal
edema.
Vital Signs
Although the normal resting heart rate usually
ranges from 50 to 90 beats/min, both slower and more rapid rates may occur in
normal individuals or may reflect noncardiac conditions such as anxiety or pain,
medication effect, fever, thyroid disease, pulmonary disease, anemia, or
hypovolemia. If symptoms or clinical suspicion warrants, an ECG should be
performed to diagnose arrhythmia, conduction disturbance, or other
abnormalities. The range of normal BP is wide, but even in asymptomatic
individuals systolic pressures below 90 mm Hg or above 140 mm Hg and diastolic
pressures above 90 mm Hg warrant further clinical evaluation and follow-up. BP
may vary between the upper extremities (often the left brachial is slightly
lower than the right) and the BP measurement in the leg is usually higher than
in the arm. Anxiety may increase the BP, and the patient should be asked if it
has been checked in other settings. The ready availability of home BP monitoring
or drugstore monitoring units should be considered before beginning
antihypertensive therapy if the BP is borderline elevated. Tachypnea is
also nonspecific, but pulmonary disease and heart failure should be considered
when respiratory rates exceed 16/min under resting conditions. Cheyne–Stokes
respiration, a form of periodic breathing is not uncommon in severe heart
failure.
Peripheral Pulses & Venous Pulsations
The quality of the pulses palpated is a reflection of the
pulse pressure. Diminished peripheral pulses most commonly result from
arteriosclerotic peripheral vascular disease and may be accompanied by localized
bruits. Asymmetry of pulses should also arouse suspicion of coarctation
of the aorta or aortic dissection, especially if a delay is noted between the
brachial or radial pulse and the femoral pulse. Exaggerated upper extremity
pulses may indicate aortic regurgitation, coarctation, patent ductus
arteriosus, or other conditions that increase stroke volume. The carotid pulse
is a valuable aid to assessment of LV ejection. It has a delayed upstroke
in aortic stenosis and a bisferiens quality (two palpable peaks) in mixed
aortic stenosis and regurgitation or hypertrophic obstructive cardiomyopathy. It
may be difficult to feel in significant aortic stenosis or in low output states.
Pulsus paradoxus (a decrease in systolic BP during inspiration) is a
normal sign unless exaggerated to > 10 mm Hg. The most common cause of pulsus
paradoxus is asthma and chronic obstructive pulmonary disease (see ECG), though
its presence may be a critical component to the diagnosis of pericardial
tamponade. Pulsus alternans, in which the amplitude of the pulse
alternates every other beat during sinus rhythm, occurs when cardiac
contractility is very depressed. It is volume dependent and at times can be
elicited by feeling the pulse on standing.
Pulmonary Examination
Rales heard at the lung bases are a sign of CHF but
may be caused by similarly localized pulmonary disease . Cardiac rales tend to
occur late in inspiration and be fine in nature, while pulmonary rales tend to
be more coarse and appear in early or mid inspiration. Rales are loudest at the
bases in heart failure, and the examiner should note how far up from the
diaphragm they are audible. Wheezing suggests obstructive pulmonary
disease and only rarely occurs in left heart failure ; . Pleural
effusions with bibasilar percussion dullness and reduced breath sounds are
common in CHF and are more frequent or larger on the right (see x-ray). Egophony
may be present due to pulmonary compression over a pleural effusion or to a
pulmonary infiltration.
Precordial Pulsations
A parasternal lift usually indicates right
ventricular hypertrophy (RVH), pulmonary hypertension (pulmonary artery [PA]
systolic pressure > 50 mm Hg), or LA enlargement; PA pulsations may also be
visible. The examiner should feel the LV apical impulse in the left lateral
position and note if it is sustained or enlarged and whether an early impulse
(A wave) precedes the main apical thrust. The A wave implies poor
LV compliance and corresponds to a fourth heart sound. If the second heart sound
is palpable along the left sternal border, it may imply an increased
P2 and pulmonary hypertension.
Heart Sounds & Murmurs.
The first heart sound (S1), the closing of the mitral valve
and tricuspid valve, may be diminished with severe LV dysfunction or accentuated
with mitral stenosis or short PR intervals. Separation of the components of
the second heart sound is due to the normally compliant lung, allowing
for continuing forward pulmonary flow with systole compared to the aortic flow
due to the less compliant arterial system. The pulmonary valve closes later than
the aortic valve for that reason (splitting). Inspiration increases flow to the
lung and reduces flow to the left heart, and splitting is increased.
Splitting may be fixed in atrial septal defect , wide with
right bundle branch block, and absent or reversed (paradoxic
splitting) with aortic stenosis, LV failure, or left bundle branch block.
With normal splitting, an accentuated P2 is an important sign of
pulmonary hypertension . Third and fourth heart sounds (ventricular and
atrial gallops, respectively) indicate ventricular volume overload or impaired
compliance and may be heard over either ventricle (; ). A right-sided gallop may
increase with inspiration or may be confirmed if heard in the right
subclavicular area (where a left-sided gallop does not usually radiate). A
palpable A wave helps confirm an S4. An apical S3
is a normal finding in younger individuals and in high output states, such as
pregnancy. Additional auscultatory findings include sharp, high-pitched sounds
classified as "clicks." These may be early systolic and represent
ejection sounds (as with a bicuspid aortic valve or pulmonary stenosis)
or may occur in mid or late systole, indicating myxomatous changes in the mitral
valve .
Edema
Subcutaneous fluid collections appear first in the lower
extremities in ambulatory patients or in the sacral region of bedridden
individuals. In heart disease, edema primarily results from elevated RA
pressures or associated peripheral venous disease. Right heart failure most
commonly results from left heart failure, pulmonary disease, or RV dysfunction
and tricuspid regurgitation, or constrictive pericarditis. Edema may also be due
to nephrotic syndrome, low serum albumin, cirrhosis, premenstrual fluid
retention, or drugs (especially vasodilators such as calcium channel blockers or
salt-retaining medications such as nonsteroidal anti-inflammatory agents or
thiazolidinedione diabetic agents), or it may be idiopathic. Ascites may
predominate, especially in constrictive pericarditis or following aggressive
diuretic usage that reduces peripheral edema.
Thanks for yout attention to Signs of Heart Disease article.
Resources:
Current Medical Diagnosis &
Treatment
Stephen J. McPhee, Maxine A. Papadakis, and Lawrence M.
Tierney, Jr., Eds.
Ralph Gonzales, Roni Zeiger, Online Eds.
Ralph Gonzales, Roni Zeiger, Online Eds.