Cardiovascular History and Examination

A careful and detail clinical assessment is essential in order to assess the likely cause and severity of symptoms, arrange appropriate investigations and referral, avoid unnecessary investigations, and to assess individual risk of cardiovascular disease or cardiomyopathy.

The commonest and most important cardiac symptoms and history are:

• Cardiac chest pain, tightness or discomfort (for a differential diagnosis, see our separate Chest Pain article)
• Shortness of breath
• Palpitations
• Blackouts, syncope or dizziness
• Related cardiovascular history, including transient ischaemic attacks, stroke, peripheral vascular disease and peripheral oedema

Chest pain

• Chest pain is very important as a symptom of heart disease, but is sometimes difficult to evaluate.
• Location: usually across the front of the chest but can also be in the upper abdomen, neck, jaw, left arm or left shoulder.
• Radiation: may spread to neck, jaw, back, left or right arm.
• Nature: usually continuous, crushing or gripping, and not sharp or interrupted.
  • Patients tend to describe the angina pains with the flat of their hand horizontally across the middle of their chest; they tend to describe oesophageal spasms with a clenched fist at the upper xiphisternum edge moving in a vertical manner.
  • Patients may refer to anginal pain as "indigestion".
• Other features include duration, aggravating and relieving factors, and associated symptoms (e.g. nausea and/or vomiting, sweating, dizziness, and palpitations).

Breathlessness

• Breathlessness is the most common symptom occurring in heart disease.
• How long has it been present?
• What brings it on? Dyspnoea on exertion is the commonest type of dyspnoea and may precede other evidence of heart failure.
• How far can they walk at a normal pace before it starts, how long does it last for after they stop?
• Any associated cough and sputum?
• Any breathlessness on lying flat (orthopnoea)? Do they have to sleep propped up at night, and if so with how may pillows?
• Any attacks waking the patient from sleep (paroxysmal nocturnal dyspnoea) or at rest? May last from minutes to hours and accompanied by wheezing, sweating, distress, and cough with frothy or bloodstained sputum (commonly termed "cardiac asthma", though uraemia may cause similar symptoms).
• Cheyne-Stokes or periodic breathing: often occurs during sleep, with a long cycle time, and may be found in chronic pulmonary oedema or poor cardiac output.

Palpitations

• Description: bumping, throbbing, or thumping.
• Rhythm: ask patient to tap out rate and regularity; missed beat or extra large bump suggests extrasystoles.
• Duration: sudden short episodes suggest paroxysmal tachycardia, longer duration with irregularities suggests atrial dysrhythmia.
• Associated symptoms: pain, dyspnoea, or faintness.

Other history to explore

• Drugs/medication: prescribed, over the counter, or illegal drug abuse
• Cough:
  • Duration, paroxysms or constant, dry or productive?
  • Associations: is it related to chest pains; any fever or shivering fits?
  • Sputum: colour, quantity, any blood in sputum (haemoptysis)
• Limb ischaemia, intermittent claudication
• Gastrointestinal symptoms: chronic heart failure may cause abdominal discomfort due to liver enlargement and abdominal distension
• May present with failure to thrive in children or weight loss in adults (though obesity is more common with weight gain in fluid retention caused by heart failure)
• Urinary symptoms: oliguria can be an important symptom of heart failure
• Cerebral symptoms:
  • Syncope of cardiac origin may closely resemble benign vasovagal attacks, and can be caused by aortic stenosis or regurgitation (or even pulmonary stenosis), and excessively fast or slow ventricular rate (heart-block, atrial dysrhythmia, and paroxysmal tachycardia)
  • Dizziness, headache, and mental changes are not uncommon symptoms of hypertension, arterial degeneration and cardiac failure

Past medical history

• Enquire about any raised blood pressure, heart problems, fainting fits, dizziness or collapses.
• Any heart attacks, any history of angina, any cardiac procedures or operations (type and date of intervention and outcome)?
• Previous levels of lipids if ever checked or known.
• Any history of rheumatic fever or heart problems as a child?
• General: any other operations or illnesses, especially history of myocardial infarction, hyperlipidaemia, hypertension, strokes, diabetes?

Family history

Ask about hypertension, ischaemic heart disease, strokes, diabetes, hyperlipidaemia, congenital heart disease, early deaths (less than aged 60) in the family.

Lifestyle

• Include ensuring appropriate primary prevention of cardiovascular disease (including calculation of cardiovascular risk) and secondary prevention of cardiovascular disease.
• Smoking
• Restrictions, including exercise tolerance: anything that they cannot do because of any of the symptoms. It is best to try and quantify, e.g. unable to walk 50 yards rather than unable to walk. What changes have they had to make, e.g. stopped walking up the stairs or stopped work, because of angina and/or breathlessness.
• Occupation: sedentary or active, and how active.
• Stress levels; occupational and others.

General

• Build (obesity or wasting), shortness of breath, difficulty in talking, do they look ill?
• Look for pallor, jaundice, sweatiness and clamminess, and for xanthelasma around eyes.

Cyanosis

• Seen below finger and toe nails, but also in lips, cheeks, ears, and nose.
• May increase in cold and on exertion.
• Cyanosis may be a very late sign in an anaemic patient due to their low haemoglobin (because cyanosis depends on a finite amount of deoxygenated haemoglobin not the ratio of deoxygenated haemoglobin).
• In patients with dark skin, cyanosis is best seen on inner lining of eyelids or inner surface of lips.

Hands

• Finger clubbing
• Splinter haemorrhages (as in infective endocarditis)
• Sweaty palms, tremor (thyrotoxicosis)
• Lax joints (Marfan's Syndrome)
• Visible capillary pulsations in nail bed (Quinke's sign - often seen in aortic regurgitation, but can occur in normal individuals if the skin is warm, and in hyperthyroidism; can also be seen by pressing glass slide on everted lip).

Pulse

• Rate: average 72, faster in children, and may slow in old age. Compare with apex rate.
• Rhythm:
  • Respiratory variations common in healthy individuals (if noticeable quickening in inspiration and slowing in expiration, is termed sinus arrhythmia).
  • Commonest irregularities are atrial arrhythmias and extrasystoles (which may disappear on exertion).
• Character:
  • Thready, strong, bounding, collapsing (" water hammer " and its 2 stroke, dicrotic/hyperdicrotic variant) or slow-rising (plateau) or anacrotic (variant of slow-rising, with extra wave on the upstroke).
  • A pulse that weakens in inspiration is called " pulsus paradoxus " (as opposed to the normal increase in volume), and is found in constrictive pericarditis, pericardial effusion, restrictive cardiomyopathy, and severe asthma.
  • Pulsus alternans (an alternate variation in size of pulse wave) is an important sign of LVF, but may be normal in presence of a fast ventricular rate.
  • Pulsus bigeminus: groups of two heartbeats close together followed by a longer pause. The second pulse is weaker than the first. Pulsus bigeminus is caused by premature ventricular contractions after every other beat. It can be a sign of heart disease, particularly hypertrophic obstructive cardiomyopathy, or may be an innocent and temporary phenomenon.
• Inequality of pulses:
  • Radials: congenital abnormality, aortic arch aneurysm, a few cases of coarctation of the aorta, supravalvular aortic stenosis (rare), Takayasu's disease and occlusion of subclavian artery by external pressure.
  • Lower limb arteries: atherosclerosis of the larger arteries is the commonest cause. Arterial embolism is an important cause in both upper and lower limbs.
  • Dissecting aortic aneurysm may cause progressive occlusion, and even reappearance if re-entry occurs.
  • Arteritis and other inflammatory diseases occasionally cause occlusion.

Check blood pressure

• Should be measured in the brachial artery using a cuff around the upper arm.
• A large cuff must be used in fat people, because a small cuff will result in the blood pressure being overestimated.
• Systolic pressure is at the level when first heard (Korotkov I) and the diastolic pressure is when silence begins (Korotkov V).
• In patients with chest pain, or if ever the radial pulses appear asymmetrical, the pressure should be measured in both arms because a difference between the two may indicate aortic dissection.

Chest examination

• Check the level of the jugular venous pressure.
• Chest examination:
  • Look to see if chest wall is deformed (e.g. funnel chest), and moves equally (inequality of expansion is usually due to respiratory disease).
  • Note the respiratory rate, it is related to the pulse rate in the ratio of about 1:4, and remains constant in the same individual.
  • Ask patient to breath out and, using both hands resting lightly on the side walls of the chest with thumbs meeting in the middle, ask them to breath in to assess the expansion of the chest on full inspiration by noting how far examiner's thumbs move apart.
  • Observe and palpate the trachea to detect any deviation to left or right (noting any thyroid swelling), (otherwise may get a false impression of cardiac enlargement if the apex beat is displaced towards the axilla).
  • Palpate and percuss to find any areas of dullness (fluid or lung collapse); palpate with the flat hand over the 5th intercostals space to feel the maximum impulse (apex of the heart) and note its position; the apex is better defined by the light use of 2 fingers (noting the rib space and its position relative to an imaginary line dropped from middle of the clavicle).
  • Feel over the anterior chest wall for any thrills associated with cardiac murmurs.
• Auscultation of the heart:
  • Also see separate article on Heart Murmurs in Children.
• Abdomen:
  • Palpate the abdomen for hepatomegaly and splenomegaly (congestive cardiac failure), or spleen alone (infective endocarditis).
  • Feel for enlargement of the aorta (aneurysm); feel with hands flat either side of the aorta feel for pulsation and tenderness.
• Peripheral pulses:
  • Femoral pulses (radial femoral delay in coarctation), and foot, and ankle pulses.
  • Listen over the renal and femoral artery for murmurs.
• Peripheral oedema:
  • Assess ankle swelling by pressing thumb firmly (not hard) above medial malleolus and see if it leaves an impression.
  • In a bed-bound patient the swelling is likely to be in the sacral area, genitalia and back of the thighs, rather than ankles.
  • Oedema is not confined to the subcutaneous tissues, but may affect serous sacs, e.g. pleural effusion, pericardial effusion, or ascites.
• Fundoscopy:
  • Look for silver wiring effect in hypertension, swollen disc in malignant hypertension, microaneurysms and fluffy deposits.
  • Also Roth spots in infective endocarditis.

Investigations

• May include ECG, ambulatory blood pressure monitoring, chest X-rays, exercise ECG testing, spirometry, lipid profile, cardiac enzyme assays and echocardiogram.