What are the key components and findings of a comprehensive cardiac and peripheral vascular assessment?

Comprehensive Cardiac and Peripheral Vascular Assessment

A thorough cardiac and peripheral vascular assessment requires systematic evaluation of cardiac anatomy, heart sounds, murmurs, pulses, and vascular sufficiency to accurately identify cardiovascular pathology and guide clinical decision-making.

Normal Cardiac Anatomy and Examination

Cardiac Anatomy

• Atria: Right atrium receives deoxygenated blood from systemic circulation; left atrium receives oxygenated blood from pulmonary veins
• Ventricles: Right ventricle pumps blood to lungs; left ventricle pumps blood to systemic circulation
• Valves:
  • Atrioventricular: Tricuspid (right), Mitral (left)
  • Semilunar: Pulmonic (right), Aortic (left)
• Blood flow: Right atrium → tricuspid valve → right ventricle → pulmonic valve → pulmonary arteries → lungs → pulmonary veins → left atrium → mitral valve → left ventricle → aortic valve → aorta → systemic circulation

Normal Cardiac Examination

• Inspection: Observe for visible pulsations, heaves, or abnormal movements
• Palpation: Assess Point of Maximal Impulse (PMI)
  • Normally located at 5th intercostal space, midclavicular line
  • Displaced PMI suggests cardiomegaly, LV hypertrophy, or volume overload 1
  • Assess for thrills (palpable vibrations associated with loud murmurs)
• Percussion: Limited utility in modern practice
• Auscultation: Systematic approach
  • Aortic area: 2nd right intercostal space
  • Pulmonic area: 2nd left intercostal space
  • Tricuspid area: Left lower sternal border
  • Mitral area: 5th intercostal space, midclavicular line
  • Listen for S1, S2, abnormal S3/S4, and murmurs

Heart Sounds

• S1: Represents closure of mitral and tricuspid valves at beginning of systole
• S2: Represents closure of aortic and pulmonic valves at end of systole
• S3: Early diastolic sound; pathological in adults, suggests volume overload or heart failure
• S4: Late diastolic sound; suggests decreased ventricular compliance or increased atrial contraction

Cardiac Murmurs

Systolic Murmurs

• Aortic stenosis: Harsh, crescendo-decrescendo systolic murmur, best heard at right upper sternal border, radiates to carotids
• Mitral regurgitation: Holosystolic murmur, best heard at apex, radiates to axilla

Diastolic Murmurs

• Aortic regurgitation: High-pitched, decrescendo diastolic murmur, best heard at left sternal border
• Mitral stenosis: Low-pitched, rumbling diastolic murmur, best heard at apex with bell of stethoscope

Murmur Grading

• Grade I: Very faint, heard only in quiet environment
• Grade II: Quiet but readily heard
• Grade III: Moderately loud, no thrill
• Grade IV: Loud with palpable thrill
• Grade V: Very loud, thrill present, audible with stethoscope barely on chest
• Grade VI: Audible with stethoscope not touching chest

Abnormal Cardiac Findings

Pericardial Friction Rub

• Scratchy, grating sound heard throughout cardiac cycle
• Caused by inflammation of pericardial surfaces (pericarditis)
• Best heard at left lower sternal border with patient leaning forward
• May have up to three components (atrial systole, ventricular systole, ventricular diastole)

Patent Ductus Arteriosus

• Congenital heart defect where connection between pulmonary artery and aorta fails to close
• Produces continuous "machinery" murmur heard throughout systole and diastole
• Best heard in left infraclavicular area

Jugular Venous Pressure (JVP)

• Reflects right atrial pressure
• Elevated JVP suggests right heart failure, tricuspid regurgitation, or pericardial tamponade
• Assessed with patient at 45° angle, measuring height of pulsation above sternal angle

Peripheral Vascular Assessment

Arterial Pulses

• Locations:
  • Carotid: Neck, medial to sternocleidomastoid
  • Brachial: Antecubital fossa, medial to biceps tendon
  • Radial: Lateral wrist
  • Femoral: Below inguinal ligament, midway between pubic symphysis and anterior superior iliac spine
  • Popliteal: Behind knee in popliteal fossa
  • Dorsalis pedis: Dorsum of foot between 1st and 2nd metatarsals
  • Posterior tibial: Behind medial malleolus

Pulse Grading

• 0: Absent
• 1+: Diminished
• 2+: Normal
• 3+: Increased
• 4+: Bounding

Arterial Insufficiency

• Subjective symptoms:
  • Intermittent claudication (leg pain with walking that resolves with rest)
  • Rest pain (severe ischemia)
  • Cold extremities
  • Numbness or paresthesias
• Physical findings:
  • Diminished or absent pulses
  • Pallor on elevation
  • Dependent rubor
  • Delayed capillary refill
  • Hair loss
  • Shiny, atrophic skin
  • Ulceration (especially at pressure points)
  • Gangrene in severe cases 1

Venous Insufficiency

• Subjective symptoms:
  • Aching, heaviness in legs
  • Swelling that worsens with prolonged standing
  • Nocturnal leg cramps
  • Pruritus
• Physical findings:
  • Edema
  • Varicose veins
  • Hyperpigmentation
  • Lipodermatosclerosis
  • Venous ulcers (typically medial malleolus)
  • Atrophie blanche (white scarring)

Carotid Bruit

• Blowing sound heard over carotid artery
• Suggests turbulent flow due to stenosis
• Associated with increased stroke risk

Differential Diagnosis of Chest Pain

Cardiac Causes

• Acute coronary syndrome (unstable angina, NSTEMI, STEMI)
• Stable angina
• Pericarditis
• Aortic dissection
• Valvular disease (especially aortic stenosis)

Pulmonary Causes

• Pulmonary embolism
• Pneumothorax
• Pleuritis
• Pneumonia

Gastrointestinal Causes

• GERD
• Esophageal spasm
• Peptic ulcer disease
• Biliary colic
• Pancreatitis

Musculoskeletal Causes

• Costochondritis
• Muscle strain
• Rib fracture
• Herpes zoster

Key Questions for Chest Pain Assessment

• Character: Pressure, sharp, burning, tearing?
• Location: Central, left-sided, radiating?
• Onset: Sudden or gradual?
• Duration: Seconds, minutes, hours?
• Exacerbating/relieving factors: Exertion, rest, position, nitroglycerin?
• Associated symptoms: Dyspnea, diaphoresis, nausea, syncope?

Special Considerations

Hemodynamic Changes During Pregnancy

• Increased blood volume (30-50%)
• Increased cardiac output (30-50%)
• Decreased systemic vascular resistance
• Physiologic murmurs common (flow murmurs)

Family History Importance

• Premature coronary artery disease
• Sudden cardiac death
• Cardiomyopathies
• Congenital heart disease
• Familial hyperlipidemia
• Arrhythmias

Common Pitfalls and Caveats

• Failing to distinguish between cardiac and non-cardiac chest pain
• Missing subtle signs of arterial insufficiency before tissue damage occurs
• Overlooking venous insufficiency as cause of leg symptoms
• Attributing all murmurs to pathology (some are benign flow murmurs)
• Inadequate assessment of peripheral pulses in patients with cardiovascular risk factors
• Failure to recognize that peripheral arterial disease is a marker for systemic atherosclerosis 1

A systematic approach to cardiac and peripheral vascular assessment provides crucial information for diagnosis, risk stratification, and management of cardiovascular conditions, significantly impacting patient morbidity and mortality.