Cardiovascular Examination
Tachycardia and hypotension could indicate volume depletion and a cause should be sought. Orthostatic hypotension (a drop of systolic BP of at least 20 mm Hg on standing) is common particularly in the older patient. Its presence does not exclude the possibility of a more serious cause of syncope.
Specific issues to consider in cardiovascular examination are (Table 1):
- Jugular venous pulse (JVP)
- Third heart sound
- Fourth heart sound
- Heart Murmurs
| Examination finding | Features | Significance |
|---|---|---|
| Elevated JVP | JVP elevated more than 5 cm above sternal angle with patient at 45 degrees | May indicate underlying cardiac failure implicated in aetiology of syncope |
| Hepatojugular reflex | A sustained rise of at least 3 cm in JVP with upper abdominal pressure. This is more easily seen as the drop in JVP when the pressure is removed. | Diagnostic of biventricular cardiac failure even in the absence of absolute elevation |
| Third heart sound | A quiet low pitched sound heard near the apex with the patient in the left lateral decubitus position. | Is a normal variant up to the age of 40 and is common in pregnant women. Otherwise suggests dilated cardiomyopathy or cardiac failure |
| Fourth heart sound | A low pitched sound best heard at the apex. More easily heard than the third sound. Very sensitive to small changes in venous filling. | Common in older patients. A loud fourth sound, a sound that does not disappear on standing, or one in a younger patient, suggests reduced ventricular compliance. It is associated with ventricular hypertrophy (e.g. secondary to aortic stenosis) or cardiac failure |
| Ejection systolic murmur | Crescendo-decrescendo murmur; usually harsh and low pitched. | In the presence of features of ventricular hypertrophy is suggestive of aortic stenosis or outflow obstruction. The murmur of hypertrophic obstructive cardiomyopathy (HOCM) is unusual in that it is one of the few murmurs that increases in intensity when the patient stands up. |