What are the key components of a cardiac physical exam for a patient with a history of cardiovascular disease or hypertension?

Cardiac Physical Examination in Patients with Cardiovascular Disease or Hypertension

In patients with cardiovascular disease or hypertension, the cardiac physical examination must systematically assess blood pressure in both arms, jugular venous pressure, heart rate and rhythm, cardiac auscultation for murmurs and gallops, peripheral pulses, and signs of congestion including edema and pulmonary rales. 1

Blood Pressure and Vital Signs Assessment

• Measure blood pressure in both arms at least once—differences in systolic BP >20 mmHg or diastolic BP >10 mmHg (if confirmed) should trigger further vascular investigations. 1
• Assess heart rate while the patient is at rest, as increased heart rate indicates elevated cardiovascular risk. 1
• An irregular pulse should raise suspicion for atrial fibrillation, including silent atrial fibrillation. 1
• Vital signs and evidence of clinical congestion should be assessed at each encounter to guide diuretic adjustment and overall management. 1

Vascular Examination

• Perform auscultation of carotid arteries, heart, and renal arteries—any murmurs detected should prompt further investigation with carotid ultrasound, echocardiography, or renal vascular ultrasound depending on location. 1
• Palpate peripheral pulses and assess for diminished or delayed femoral pulses compared to brachial pulses, which suggests aortic coarctation or lower extremity arterial disease. 1
• The presence of bruits or pulse deficits indicating extracardiac vascular disease identifies patients with higher likelihood of significant coronary artery disease and worse prognosis. 1

Assessment for Congestion and Heart Failure

Clinical congestion assessment is critical and includes:

• Jugular venous distention to assess central venous pressure and volume status. 1, 2
• Orthopnea (dyspnea when lying flat) as a marker of elevated cardiac filling pressures. 1
• Bendopnea (dyspnea when bending forward) as an additional congestion marker. 1
• Peripheral edema in the lower extremities. 1
• Pulmonary rales on chest auscultation indicating pulmonary congestion. 1
• A square-wave response to the Valsalva maneuver indicates elevated filling pressures. 1

These congestion markers are associated with quality of life and prognosis, and guide titration of diuretics and other therapies. 1

Cardiac Auscultation

• Listen for an S3 gallop, which indicates left ventricular dysfunction and identifies patients at high risk for poor outcomes. 1
• Assess for murmurs that may indicate valvular heart disease or acute mitral regurgitation, both suggesting severe underlying coronary disease and high risk. 1
• Cardiac auscultation may reveal arrhythmias requiring further evaluation. 1

Anthropometric Measurements

• Measure height, weight, and waist circumference with the patient standing, and calculate BMI. 1
• These measurements help assess cardiovascular risk and guide management strategies. 1

Assessment for Secondary Hypertension

Look for specific physical findings suggesting secondary causes:

• Features of Cushing syndrome (central obesity, moon facies, striae). 1
• Palpation of enlarged kidneys suggesting polycystic kidney disease. 1
• Abdominal murmurs suggesting renovascular hypertension. 1
• Precordial or chest murmurs indicating aortic coarctation or aortic disease. 1

Assessment for Organ Damage

• Neurological examination for motor or sensory defects indicating cerebrovascular disease. 1
• Fundoscopy to assess for hypertensive retinopathy, hemorrhages, exudates, or papilloedema (the latter indicating hypertensive emergency). 1

Common Pitfalls to Avoid

• Do not rely on a single blood pressure measurement—confirm hypertension with repeated measurements and consider out-of-office monitoring. 1
• Do not dismiss subtle signs of congestion—even mild jugular venous distention or trace edema can indicate elevated filling pressures requiring treatment adjustment. 1
• Do not skip bilateral arm blood pressure measurement—this one-time assessment can identify significant vascular abnormalities. 1
• Physical examination findings of left ventricular dysfunction (rales, S3 gallop) or acute mitral regurgitation identify high-risk patients requiring aggressive management. 1