Cardiovascular Assessment and Diagnostic Evaluation
Assessment
A focused cardiovascular exam starts with the symptom story - OPQRST for chest pain, dyspnea, orthopnea, PND, syncope, palpitations, edema, and NYHA functional class - plus the medication list, since drugs explain many findings. Then inspect, palpate, and auscultate the five valve areas, noting S1/S2, splits, extra sounds, murmurs, JVD, carotid upstrokes, pulse amplitude, capillary refill, dependent edema, and skin temperature and hair distribution.
Diagnostics
ECG interpretation follows a fixed sequence: rate, rhythm, axis, intervals (PR 0.12–0.20 s, QRS <0.12 s, corrected QT), ST-T changes, and Q waves. Labs include serial troponin (a rise and/or fall is required), BNP/NT-proBNP, electrolytes, renal function, CBC, coagulation studies, lipids, and TSH. Imaging includes echocardiography (EF, wall motion, valves), exercise or pharmacologic stress testing, coronary angiography, CT angiography, and cardiac MRI. Hemodynamic norms: CVP 2–6 mmHg, PA systolic 15–30 mmHg, PAWP 6–12 mmHg, cardiac output 4–8 L/min, index 2.5–4.0, SVR 800–1200 dynes.
Common traps
- S3 reflects volume overload (heart failure); S4 reflects a stiff ventricle (ischemia, hypertrophy). S3 is normal only in youth and pregnancy.
- Diastolic murmurs are almost always pathologic; some systolic murmurs are benign flow murmurs.
- BNP is falsely low in obesity and falsely high in renal failure and with advancing age.
- A single troponin does not diagnose MI without a rise/fall pattern and ischemic evidence.
- Hypokalemia and hypomagnesemia amplify QT-prolonging drug risk and torsades.
Rule of thumb
Estimate CVP at the bedside with the patient at 30–45°: measure JVD height above the sternal angle and add 5 cm. JVD 3 cm above the angle ≈ 8 cm H₂O ≈ 8 mmHg (normal 2–6).