Chapter 1

Cardiovascular Physical Examination

Salvatore Mangione, MD

Editor’s Note to Readers: For an excellent and more detailed discussion of the cardiovascular physical examination, read Physical Diagnosis Secrets, ed 2, by Salvatore Mangione.

1. What is the meaning of a slow rate of rise of the carotid arterial pulse?

    A carotid arterial pulse that is reduced (parvus) and delayed (tardus) argues for aortic valvular stenosis. Occasionally this also may be accompanied by a palpable thrill. If ventricular function is good, a slower upstroke correlates with a higher transvalvular gradient. In left ventricular failure, however, parvus and tardus may occur even with mild aortic stenosis (AS).

2. What is the significance of a brisk carotid arterial upstroke?

    It depends on whether it is associated with normal or widened pulse pressure. If associated with normal pulse pressure, a brisk carotid upstroke usually indicates two conditions:

 Simultaneous emptying of the left ventricle into a high-pressure bed (the aorta) and a lower pressure bed: The latter can be the right ventricle (in patients with ventricular septal defect [VSD]) or the left atrium (in patients with mitral regurgitation [MR]). Both will allow a rapid left ventricular emptying, which, in turn, generates a brisk arterial upstroke. The pulse pressure, however, remains normal.

 Hypertrophic cardiomyopathy (HCM): Despite its association with left ventricular obstruction, this disease is characterized by a brisk and bifid pulse, due to the hypertrophic ventricle and its delayed obstruction.

If associated with widened pulse pressure, a brisk upstroke usually indicates aortic regurgitation (AR). In contrast to MR, VSD, or HCM, the AR pulse has rapid upstroke and collapse.

3. In addition to aortic regurgitation, which other processes cause rapid upstroke and widened pulse pressure?

    The most common are the hyperkinetic heart syndromes (high output states). These include anemia, fever, exercise, thyrotoxicosis, pregnancy, cirrhosis, beriberi, Paget disease, arteriovenous fistulas, patent ductus arteriosus, aortic regurgitation, and anxiety—all typically associated with rapid ventricular contraction and low peripheral vascular resistance.

4. What is pulsus paradoxus?

    Pulsus paradoxus is an exaggerated fall in systolic blood pressure during quiet inspiration. In contrast to evaluation of arterial contour and amplitude, it is best detected in a peripheral vessel, such as the radial artery. Although palpable at times, optimal detection of the pulsus paradoxus usually requires a sphygmomanometer. Pulsus paradoxus can occur in cardiac tamponade and other conditions.

5. What is pulsus alternans?

    Pulsus alternans is the alternation of strong and weak arterial pulses despite regular rate and rhythm. First described by Ludwig Traube in 1872, pulsus alternans is often associated with alternation of strong and feeble heart sounds (auscultatory alternans). Both indicate severe left ventricular dysfunction (from ischemia, hypertension, or valvular cardiomyopathy), with worse ejection fraction and higher pulmonary capillary pressure. Hence, they are often associated with an S₃ gallop.

6. What is the Duroziez double murmur?

    The Duroziez murmur is a to-and-fro double murmur over a large central artery—usually the femoral, but also the brachial. It is elicited by applying gradual but firm compression with the stethoscope’s diaphragm. This produces not only a systolic murmur (which is normal) but also a diastolic one (which is pathologic and typical of AR). The Duroziez murmur has 58% to 100% sensitivity and specificity for AR.

7. What is the carotid shudder?

    Carotid shudder is a palpable thrill felt at the peak of the carotid pulse in patients with AS, AR, or both. It represents the transmission of the murmur to the artery and is a relatively specific but rather insensitive sign of aortic valvular disease.

8. What is the Corrigan pulse?

    The Corrigan pulse is one of the various names for the bounding and quickly collapsing pulse of aortic regurgitation, which is both visible and palpable. Other common terms for this condition include water hammer, cannonball, collapsing, or pistol-shot pulse. It is best felt for by elevating the patient’s arm while at the same time feeling the radial artery at the wrist. Raising the arm higher than the heart reduces the intraradial diastolic pressure, collapses the vessel, and thus facilitates the palpability of the subsequent systolic thrust.

9. How do you auscultate for carotid bruits?

    To auscultate for carotid bruits, place your bell on the neck in a quiet room and with a relaxed patient. Auscultate from just behind the upper end of the thyroid cartilage to immediately below the angle of the jaw.

10. What is the correlation between symptomatic carotid bruit and high-grade stenosis?

    It’s high. In fact, bruits presenting with transient ischemic attacks (TIAs) or minor strokes in the anterior circulation should be evaluated aggressively for the presence of high-grade (70%-99%) carotid stenosis, because endarterectomy markedly decreases mortality and stroke rates. Still, although presence of a bruit significantly increases the likelihood of high-grade carotid stenosis, its absence doesn’t exclude disease. Moreover, a bruit heard over the bifurcation may reflect a narrowed external carotid artery and thus occur in angiographically normal or completely occluded internal carotids. Hence, surgical decisions should not be based on physical examination alone; imaging is mandatory.

11. What is central venous pressure (CVP)?

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1. Exercise Stress Testing
2. Stroke and Transient Ischemic Attack
3. Endomyocardial Biopsy
4. Pulmonary Hypertension

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