Nonauscultatory Cardiac Exam: Assessing the Elderly Person

Mark E. Williams, MD

Disclosures

July 08, 2011

In This Article

Overview

The primary purpose of the cardiac examination is to assess the structure and function of the heart as a muscular pump and to evaluate it for possible malfunctions. Because heart disease is so common in elderly people, this examination often provides significant information. Proficiency in basic bedside cardiac examination is also important because some settings such as the nursing home or the patient's home do not have ready access to high technology. The skillful clinician has an advantage in relatively resource-poor settings.

Inspection

Examine the Skin for Indications of Cardiac Disease

Maculopapular skin lesions on the upper extremities can be seen in end-stage heart failure (Robertson's sign).

Examine the Neck Veins

Examining the neck veins is important, as it is usually the first step of the cardiac examination. The objectives are the careful inspection of the waveform and the estimation of the central venous pressure.

Always examine the patient's neck from the right side; this approach provides a more accurate determination of venous waves than from the left, since it is a straight shot from the right jugular veins to the superior vena cava and right atrium. Have the patient begin supine and then elevate the examining table until the top (meniscus) of the jugular venous pulse wave is evident.

Have the patient turn his or her head slightly to the left and look just lateral to the lateral head of the sternocleidomastoid (SCM) to see if the internal jugular pulsation is visible (if so use it). Sometimes the pulsation will be just inferior to the lateral head and occasionally it will be between the 2 heads of the SCM; if the internal jugular pulsation is visible, use it. Look along the right supraclavicular fossa for the external jugular vein. Confirm the vein by gently compressing it at the base of the neck and watching it distend, and then release it.

Estimating the Central Venous Pressure

Observe the height of the column of blood in each of the veins and use the most distended one in your calculation. Note the highest level of the pulsation. More than 3 cm above the clavicle with the patient at 45 degrees is abnormal. The level of the clavicle is approximately 10 cm above the right atrium when the patient is sitting upright (at 90 degrees). You can estimate the central venous pressure by standing back and determining the relative position of the right atrium (about midway down the sternum and in the midaxillary line) and the height of the column of blood. From this frame of reference, up to 16 cm of water is normal.

Next, pay attention to the variations in the jugular venous pressure (JVP) with respiration. You should see the veins collapse with inspiration, which is normal. An increase in JVP with inspiration (Kussmaul's sign) suggests a problem with right atrial filling, which is usually caused by constrictive pericarditis or right ventricular failure. In this case, consider right ventricular infarction.

Assessing Jugular Venous Wave Forms

The next step is to study the venous waveforms. The normal jugular venous pulse consists of 3 positive waves ("a," "c," and "v") and 2 negative descents ("x" and "y"). These waves reflect events in the cardiac cycle on the right side of the heart.

The "x" and "y" descents. Look particularly for the 2 downward motions -- the "x" and "y" descents -- for each upward motion. The "x" descent results from right atrial filling while the "y" descent reflects right ventricular filling. (Sometimes, the "y" descent will look like a little bounce at the end of systole.) Both descents are normally seen for each cardiac cycle.

When only 1 descent is seen, determine which is missing by feeling the pulse. If the descent you see is coincident with the pulse, this indicates that the "x" descent is present and the "y" descent is missing, implying a problem with right ventricular filling such as cardiac tamponade or tricuspid stenosis. (Tricuspid stenosis is also characterized by giant "a" waves; the "a" wave is the dominant waveform in the jugular venous pulse and is produced by atrial contractions.) Seeing the descent discordant with the pulse means the "y" descent is visible and the "x" descent is missing, implying a problem with right atrial filling such as pericardial constriction or tricuspid regurgitation. (Giant "v" waves are present in tricuspid regurgitation.) If the pulsation is synchronous with the pulse, palpate what might be the vein. If the pulse is bounding, you are probably observing the carotid artery.

The "a" and "c" waves. Note the "a" (atrial contraction) wave at the top of the venous pulse. Bounding giant "a" waves are seen in tricuspid stenosis (along with the loss of the "y" descent). Intermittent large "a" waves are canon "a" waves seen in third-degree atrioventricular block (when the right atrium contracts while the tricuspid valve is closed). The presence of 2 pulsations suggests visible "a" and "c" waves, implying first-degree atrioventricular block as the interval between the "a" wave and the "c" wave (cusp of the tricuspid valve at the beginning of right ventricular systole) reflects the PR interval on the electrocardiogram. The "a"-"c" wave interval is normally too short to allow for visualization of both waves, so when you can see the "a" and the "c" you know that the interval is prolonged (first-degree atrioventricular block). (Sometimes, the 2 waves are the "a" and "v" waves.)

The "v" wave. Note the "v" wave (volume of blood entering the right atrium), which is usually the little bounce you see after the "x" descent. Large "v" waves, replacing the "x" wave, suggest tricuspid insufficiency (Lancisi's sign).

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