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ECG
AOP
CP
OS
S4
Apex
S1
ES SC
S3
LSB
ACG
S1
S2
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
RF
JVP
A2 P2
v
x
FIGURE 9-1
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.
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.
CHAPTER 9
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.