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Examination of the upper and lower extremities may provide important diagnostic information. Palpation of the
peripheral arterial pulses in the upper and lower extremities is necessary to dene the adequacy of systemic blood
ow and to detect the presence of occlusive arterial
lesions. Atherosclerosis of the peripheral arteries may produce intermittent claudication of the buttock, calf, thigh,
or foot, with severe disease resulting in tissue damage of
the toes. Peripheral atherosclerosis is an important risk
factor for coincident ischemic heart disease.
The ankle-brachial index (ABI) is useful in cardiovascular risk assessment.The ABI is the ratio of the systolic
blood pressure at the ankle divided by the higher of the
two arm systolic blood pressures. It reects the degree of
lower-extremity arterial occlusive disease, which is manifest by reduced blood pressure distal to stenotic lesions.
Either posterior tibial or dorsalis pedis artery pressures
can be used. It is important to note that each equally
reects the status of the aortoiliac and femoropopliteal
segments but different tibial arteries; therefore, the

The normal central aortic pulse wave is characterized by

a fairly rapid rise to a somewhat rounded peak (Fig. 9-1).
The anacrotic shoulder, present on the ascending limb,
occurs at the time of peak rate of aortic ow just before
maximum pressure is reached. The less-steep descending
limb is interrupted by a sharp downward deection,
coincident with aortic valve closure, called the incisura.
As the pulse wave is transmitted distally, the initial upstroke
becomes steeper, the anacrotic shoulder becomes less
apparent, and the smoother dicrotic notch replaces the





A2 P2


A. Schematic representation of electrocardiogram, aortic
pressure pulse (AOP), phonocardiogram recorded at the
apex, and apex cardiogram (ACG). On the phonocardiogram,
S1, S2, S3, and S4 represent the rst through fourth heart
sounds; OS represents the opening snap of the mitral valve,
which occurs coincident with the O point of the apex cardiogram. S3 occurs coincident with the termination of the rapidlling wave (RFW) of the ACG, while S4 occurs coincident
with the a wave of the ACG. B. Simultaneous recording of
electrocardiogram, indirect carotid pulse (CP), phonocardiogram along the left sternal border (LSB), and indirect jugular
venous pulse (JVP). ES, ejection sound; SC, systolic click.

Physical Examination of the Cardiovascular System

The diameter of the abdominal aorta should be estimated. A pulsatile, expansible mass is indicative of an
abdominal aortic aneurysm (Chap. 38). An abdominal
aortic aneurysm may be missed if the examiner does not
assess the area above the umbilicus.
Specic abnormalities of the abdomen may be secondary to heart disease. A large, tender liver is common
in patients with heart failure or constrictive pericarditis.
Systolic hepatic pulsations are frequent in patients with
tricuspid regurgitation. A palpable spleen is a late sign in
patients with severe heart failure and is also often evident in patients with infective endocarditis. Ascites may
occur with heart failure alone, but it is less common
with the use of diuretic therapy. Constrictive pericarditis
should be considered when the ascites is out of proportion to peripheral edema. When there is an arteriovenous stula, a continuous murmur may be heard over
the abdomen. A systolic bruit heard over the kidney
areas may signify renal artery stenosis in patients with
systemic hypertension.



resulting ABIs may differ. An arm systolic pressure of 63

120 mmHg and an ankle systolic pressure of 60 mmHg
yields an ABI of 0.5 (60/120). The ABI is inversely
related to disease severity. A resting ABI <0.9 is considered abnormal. Lower values correspond to progressively
more severe occlusive peripheral arterial disease (PAD)
and disabling claudication. An ABI <0.3 is consistent
with critical ischemia, rest pain, and tissue loss.
Thrombophlebitis often causes pain (in the calf or
thigh) or edema, and when present, pulmonary emboli
should be considered as well. Edema of the lower extremities is a sign of heart failure but may also be secondary to
local factors, such varicose veins or thrombophlebitis, or
to the removal of veins at coronary artery bypass surgery.
Under such circumstances, the edema is often unilateral.

Retinal emboli have particular cardiovascular importance. Of these, platelet emboli are both the most common and the most evanescent. Hollenhorst cholesterol
plaques may be detected at the same bifurcations for
months to years after the embolic shower. Platelet emboli,
Hollenhorst plaques, and calcium emboli are usually seen
along the course of a retinal artery, and their presence
indicates that a patient is shedding from the heart, aorta,
great vessels, or carotid arteries.