Cardiac Auscultation in the Older Adult

Mark E. Williams, MD


January 18, 2012

In This Article

General Comments

Editor's Note: Before reading this article, it is recommended that readers first review "Nonauscultatory Cardiac Exam: Assessing the Elderly Person," previously published on Medscape.

As with most clinical procedures, in performing cardiac auscultation in the elderly patient, preparation, orientation, and self-discipline are key.

The following are some basic steps. The better you become at this procedure, the more important these simple points become.

First, use a good stethoscope. (This can be challenging in isolation suites equipped with toy-like disposable stethoscopes.) Make sure the patient is comfortable and let him or her know that you are going to listen carefully to the heart. Make the examining room as quiet as possible. Turn off electrical devices when possible, ask people to stop talking, and close the door.

Begin with the diaphragm and take your time; perform the examination correctly and carefully. Orient yourself to the cardiac cycle by feeling the carotid or brachial pulse. In each location, listen carefully to the first (S1) then second (S2) heart sounds, systole (the space between S1 and S2), early diastole (just after S2), and late diastole (just prior to S1). Focus all your awareness on each specific item until you are sure of what you are hearing.

Determining the Heart Rate and Rhythm

If you have not already felt the pulse, appreciate the heart rate and rhythm. A fast rate (tachycardia) is greater than 100 beats/min. A slow rate (bradycardia) is less than 60 beats/min. A normal heart rate is between 60 and 100 beats/min. A steady, predictable rhythm is regular and normal. An occasionally irregular rhythm might suggest the following:

  • premature ventricular contraction (PVC)

  • premature atrial contractions (PAC), or

  • atrial fibrillation with second-degree atrial ventricular (AV) block (think possible digitalis toxicity, if the patient is on digitalis).

A predictably irregular rhythm can suggest the following:

  • bigeminy, trigeminy, etc.,

  • respiratory variations, or

  • second-degree Mobitz type I AV block (go back and check the neck veins for increasing a-c wave interval).

Finding an irregularly irregular rhythm suggests the following:

  • atrial fibrillation (check the pulse deficit by subtracting the peripheral [radial] pulse rate from the auscultated pulse rate), or

  • atrial flutter with variable AV block.