Signs of Heart Disease

Although the cardiovascular examination centers on the heart, peripheral signs are often invaluable.

Appearance
While 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. Patients with severe congestive heart failure or other chronic 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. Central cyanosis may be caused by pulmonary disease, left heart failure, or right-to-left shunting; the latter will not be improved by increasing the inspired oxygen concentration. Pallor usually indicates anemia but may be a sign of low cardiac output.

Vital Signs
Although the normal 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 electrocardiogram (ECG) should be performed to diagnose arrhythmia, conduction disturbance, or other abnormality. The range of normal blood pressure 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. Initially elevated pressures may decline if the patient is allowed to relax and rest comfortably. Tachypnea is also nonspecific, but pulmonary disease and heart failure should be considered when respiratory rates exceed 16/min under resting conditions. Periodic breathing (Cheyne-Stokes respiration) is not uncommon in severe heart failure.

Peripheral Pulses & Venous Pulsations
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. Exaggerated 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 left ventricular ejection. It has a delayed upstroke in aortic stenosis and a quality (two palpable peaks) in mixed aortic stenosis and regurgitation or hypertrophic obstructive cardiomyopathy. paradoxus (a decrease in systolic blood pressure during inspiration greater than the normal 10 mm Hg) is a valuable sign of pericardial tamponade, though it also occurs in asthma and chronic obstructive pulmonary disease. , in which the amplitude of the pulse alternates every other beat during sinus rhythm, occurs when cardiac contractility is very depressed or with large pericardial effusions.