Physical Examination - Diagnosing Heart Disease: Heart Disease

Content provided by the Faculty of the Harvard Medical School

Physical examination

During a routine examination, most doctors check their patients' vital signs, including blood pressure (see Table 3 for what the results mean), and count the number and regularity of heartbeats (pulse) and breaths (respirations) per minute. You can check your own pulse by placing your forefinger on your wrist near the base of your thumb to feel the pulse of the radial artery as it supplies blood to the hand. Count the number of pulses during 15 seconds and multiply by four. Most people have heart rates of 60–80 beats per minute. Some well-conditioned athletes have rates in the 40s and 50s. But a resting heart rate of 100 or more beats per minute may mean the heart is working extra hard because of some underlying problem.

Your doctor may also measure your breathing rate. If you are sitting quietly, more than about 20 breaths per minute may indicate a problem with your heart or lungs. But, again, it's important to remember that no single sign is definitive: Most people with coronary artery disease have normal heart and breathing rates.

Murmurs and gallops

Physicians can detect the disruption of blood flow caused by coronary artery disease by listening to the chest for heart murmurs and for extra sounds called gallops that may result from damage to the heart. A heart murmur is an abnormal sound caused by the flow of blood through heart chambers or valves. Some heart murmurs do not indicate heart problems, but others do.

A heart murmur can be caused indirectly by coronary artery disease if inadequate blood flow through the coronary arteries deprives the muscles controlling the heart's mitral valve of the oxygen it needs to function normally. If this valve fails to close completely during each contraction of the left ventricle, blood can be squeezed backward through the valve into the left atrium — a syndrome called mitral regurgitation. Unless the amount of mitral regurgitation is quite minimal, it will produce a murmur that can be detected with a stethoscope.

Gallops are abnormal dull, soft, thudding noises that the heart makes when it fills with blood. An S3 gallop can occur when blood rushes into a stiff, damaged left ventricle as it begins to fill for the next heartbeat. An S4 gallop is a similar sound that occurs at the end of the filling period just before the left ventricle starts to contract; this gallop is caused by the surge in blood flow that occurs with contraction of the left atrium, the chamber that pumps blood to the left ventricle.

These sounds are not always a sign of coronary artery disease, but they indicate a stiffness of the heart's main pumping chamber. In fact, S4 gallops are extremely common among older people, particularly if they have hypertension, and many young, healthy people have S3 gallops. Although such gallops are usually nothing to worry about, if you have them, get checked periodically by your doctor for signs of heart trouble.

Lungs, neck, feet

When looking for evidence that the heart muscle has been weakened, physicians don't examine only the heart. If the heart has been damaged by a heart attack, compromising its ability to pump blood, fluid tends to accumulate in the lungs, veins, and the rest of the body — a condition called congestive heart failure. Therefore, doctors listen to the lungs for crackling noises, or rales, that might indicate fluid congestion. Doctors also scrutinize the veins of the neck, because these vessels become distended when the blood has difficulty getting through the heart. Doctors also press over the shinbones to see if fluid has accumulated in the legs. Such a fluid buildup is called edema.

The doctor feels the strength of the pulse in the feet, which may be weakened if there is severe atherosclerosis in the major arteries feeding the legs, a condition known as peripheral artery disease. By placing a stethoscope against your neck, a physician can sometimes hear soft noises, called bruits, which result from turbulence caused by atherosclerosis in the carotid arteries. Sometimes, by looking into your eye with an ophthalmoscope, your doctor can see abnormalities in the small vessels of the retina. If atherosclerosis exists in these vessels, there's an above-average chance that you may also have coronary artery disease.

In addition to evaluating the blood vessels, the physician does a complete physical examination in search of clues to the health of your cardiovascular system, as well as to exclude other medical problems. For example, he or she may look for a ring around the iris of your eye or fat-filled nodules just under your skin, particularly on your elbows, hands, and heels. These are symptoms of high blood cholesterol levels. Some data even suggest that deep creases at the bottom of the earlobes may be especially common in people with coronary artery disease, although the mechanism and importance of this possible association is unknown.

Last updated:	May 03, 2007