cardiovascular disorders
Cardiovascular Examination
Vital Signs
Vital signs include Blood pressure Heart rate and rhythm Respiratory rate Temperature Additional data often obtained along with vital signs include patient weight and peripheral oxygen saturation (SpO2). Blood pressure(BP) is measured in both arms and, for suspected congenital cardiac disorders or peripheral vascular disorders, in both legs. The bladder of an appropriately sized cuff encircles 80% of the limb’s circumference, and the bladder’s width is 40% of the circumference. When measured by auscultation, the first sound heard as the mercury column falls is systolic pressure; disappearance of the sound is diastolic pressure (5th-phase Korotkoff sound). Up to a 15 mm Hg pressure differential between the right and left arms is normal; a greater differential suggests a vascular abnormality (eg, dissecting thoracic aorta) or a peripheral vascular disorder. Leg pressure is usually 20 mm Hg higher than arm pressure. In many clinical settings, blood pressure is measured using an automated device. To obtain an accurate blood pressure measurement, the patient should Be seated in a chair (not on the examination table) for > 5 minutes, feet on floor, back supported Have the limb supported at heart level with no clothing covering the area of cuff placement Abstain from exercising, consumingcaffeine, or smoking for at least 30 minutes before the measurement is taken are assessed by palpating the carotid or radial pulse, by using a pulse oximeter or automated blood pressure cuff with that function, or, if Overview of Arrhythmias is suspected, by cardiac auscultation; some heartbeats during arrhythmias may be audible but do not generate a palpable pulse. if abnormal, may indicate cardiac decompensation or a primary lung disorder. The rate increases in patients with Heart Failure (HF) or may be elevated by acute Rheumatic Fever or cardiac infection (eg, is collected at each clinic visit with the patient on a standing scale and, ideally, while wearing a similar amount of clothing. In patients with heart failure, weight gain may indicate hypervolemia, while weight loss may indicate cardiac cachexia (unintentional, non-edematous weight loss of > 5% within the last 12 months— Vital signs references ). 95% suggest hypoxemia. A notable exception to this cutoff value is in patients with Chronic Obstructive Pulmonary Disease (COPD) (COPD); in these patients, the target SpO2 can be 88 to 92%. When hypoxemia is present, potential cardiac etiologies include The ankle-brachial index (ABI) is the ratio of systolic blood pressure (BP) in the ankle to that in the arm. With the patient recumbent, the ankle blood pressure is measured in both the dorsalis pedis and posterior tibial artery, and the arm blood pressure is measured in both arms at the brachial artery. The index is calculated for each lower extremity by dividing the higher of the dorsalis pedis or posterior tibial pressure in that extremity by the higher of the 2 brachial artery systolic pressures. This ratio is normally>1. A Doppler probe may be used to measure blood pressure at the ankle if the pedal pulses are not easily palpable. A low (≤ 0.90) ankle-brachial index suggests Peripheral Arterial Disease , which can be classified as mild (index 0.71 to 0.90), moderate (0.41 to 0.70), or severe (≤ 0.40). A high index (> 1.30) may indicate noncompressible leg vessels, as may occur in conditions that are associated with blood vessel calcification, for example, Blood pressure and heart rate are measured with the patient supine, seated, and standing; a 1-minute interval is needed between each change in position. Orthostatic hypotension is typically defined as a decrease in systolic blood pressure of>20 mm Hg or diastolic blood pressure>10 mm Hg and a change in heart rate of>20 beats per minute within 3 minutes of standing; the difference in blood pressure tends to be a little greater in older patients due to loss of vascular elasticity. The patient should be asked about symptoms of cerebral hypoperfusion, including lightheadedness or vision changes. However, the sensitivity of these measurements to detect hypovolemia (eg, secondary to blood loss) is low. Causes of abnormal orthostatic vital signs include hypovolemia, baroreflex dysfunction (eg, due to neurodegenerative disorders such as Autonomic Neuropathies , peripheral neuropathies, older age) and, less commonly, valvular disease (eg, aortic stenosis), heart failure, or arrhythmias. Certain medications (eg, diuretics, vasodilators) can also contribute to abnormal orthostatic vital signs ( Normally during inspiration, systolic arterial blood pressure can decrease as much as 10 mm Hg, and pulse rate increases to compensate. An exaggeration of this normal response with a greater decrease in systolic blood pressure or weakening of the pulse during inspiration is considered pulsus paradoxus. Pulsus paradoxus occurs in Cardiac Tamponade (commonly) Pathophysiology None Restrictive Cardiomyopathy None Chronic obstructive pulmonary disease (occasionally) Severe asthma Severe pulmonary embolism Hypovolemic shock (rarely) Blood pressure decreases during inspiration because negative intrathoracic pressure increases venous return and hence right ventricular (RV) filling; as a result, the interventricular septum bulges slightly into the left ventricular (LV) outflow tract, decreasing cardiac output and thus BP. This mechanism (and the drop in systolic BP) is exaggerated in disorders that cause high negative intrathoracic pressure (eg, asthma) or that restrict RV filling (eg, cardiac tamponade, cardiomyopathy) or outflow (eg, pulmonary embolism). Pulsus paradoxus is quantified by inflating a BP cuff to just above systolic BP and deflating it very slowly (eg,≤2 mm Hg/heartbeat). The pressure is noted when Korotkoff sounds are first heard (at first, only during expiration) and when Korotkoff sounds are heard continuously. The difference between the pressures is the “amount” of pulsus paradoxus. 1.Lena A, Ebner N, Anker MS: Cardiac cachexia.Eur Heart J Suppl21 (Suppl L): L24–L27, 2019. 2.Wieling W, Kaufmann H, Claydon VE, et al: Diagnosis and treatment of orthostatic hypotension.Lancet Neurol21(8):735–746, 2022. doi:10.1016/S1474-4422(22)00169-7 