The cardiovascular examination

01Purpose and principlesWhat the assessment is for and the core concepts behind it.

A useful cardiovascular examination begins with physiology: perfusion, congestion, rhythm, valve flow and peripheral arterial supply. The sequence should never postpone recognition of instability.

Describe findings rather than jumping to labels: pulse rate/rhythm/volume; JVP height/waveform; apex site/character; murmur timing, site, radiation, intensity and response to manoeuvres; lung and peripheral findings.

Classic signs are imperfect. Absence of a murmur does not exclude severe valve disease in low flow, absence of crackles does not exclude chronic heart failure, and palpable pulses do not exclude dissection or PAD.

A complete examination finishes with a concise synthesis and a focused plan—for example, irregularly irregular pulse plus stroke risk prompts ECG; exertional syncope plus systolic murmur prompts urgent cardiovascular assessment and echocardiography.

Key points

Introduce yourself, confirm identity, obtain consent, ask about pain, position at about 45 degrees and expose from chest to ankles while preserving dignity.
From the end of the bed assess distress, work of breathing, colour, diaphoresis, body habitus, scars, oxygen, lines and implanted devices.
In the hands assess temperature, capillary refill, clubbing, splinter haemorrhages and peripheral stigmata, then measure radial pulse rate and rhythm; character is better assessed centrally when safe.
Measure BP with the correct cuff; initially use both arms. Check standing BP when dizziness/falls, type 2 diabetes, age 80 or older or treatment effects suggest postural hypotension.
Inspect the face for conjunctival pallor, central cyanosis and lipid signs, then assess the JVP at 30–45 degrees and palpate each carotid separately.
Inspect and palpate the precordium for scars, apex position/character, parasternal heave and thrills before auscultating the four valve areas with diaphragm and bell.
Use targeted manoeuvres: left lateral position and bell for a mitral stenosis rumble; sit forward, end expiration for aortic regurgitation; inspiration augments many right-sided murmurs.
Complete the circulation: lung bases, sacrum/ankles, abdomen including liver and aortic pulsation when appropriate, and lower-limb pulses, temperature and wounds.
Examination generates probabilities, not exclusions. Order ECG, echo, biomarkers or vascular imaging according to the dominant finding and urgency.

02Indications, selection and cautionsWhen it is useful, when urgency changes and important limitations.

Shock or peri-arrest physiologyRed flag

Systolic BP below 90 mmHg with poor perfusion, altered consciousness, cold/mottled skin, oliguria, severe breathlessness or abnormal breathing requires immediate ABCDE/resuscitation rather than completion of the OSCE sequence.

Acute coronary syndromeRed flag

Ongoing pressure-like chest pain, diaphoresis, nausea, haemodynamic change or ischaemic ECG findings; examination may be normal and must not delay a 12-lead ECG.

Unstable arrhythmiaRed flag

Tachycardia or bradycardia with shock, syncope, myocardial ischaemia or severe heart failure/pulmonary oedema requires the RCUK peri-arrest algorithm.

Valve red flagsRed flag

A systolic murmur with exertional syncope, or murmur with severe breathlessness/angina at minimal exertion or rest, needs urgent specialist/echo assessment. New acute AR/MR with pulmonary oedema or shock is an emergency.

Heart failureRed flag

Raised JVP, displaced apex, third heart sound, basal crackles, oedema, orthopnoea or exertional breathlessness; acute hypoxia/distress requires emergency assessment, while suspected chronic disease follows NT-proBNP time thresholds.

Peripheral or aortic vascular emergencyRed flag

Abrupt chest/back pain with pulse deficit or new AR suggests AAS; a cold painful pulseless limb with sensory/motor loss suggests acute limb ischaemia. Both need immediate specialty pathways.

03Method and interpretationA systematic approach to the test and its findings.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
12-lead ECG within the acute pathwayFirst step
Why
Assess chest pain, dyspnoea, syncope, irregular pulse, brady/tachycardia and suspected structural disease.
Interpretation and limitations
An irregular pulse mandates ECG for AF diagnosis. In suspected ACS, repeat ECGs because a normal first tracing does not exclude ischaemia.
02
Ambulatory ECG
Why
Correlate intermittent symptoms with rhythm when the 12-lead ECG is unrevealing.
Interpretation and limitations
For suspected paroxysmal AF, use 24-hour monitoring when episodes are less than 24 hours apart or asymptomatic; use longer event monitoring when more than 24 hours apart.
03
Transthoracic echocardiography
Why
Assess murmur plus symptoms/signs, abnormal ECG, suspected heart failure or structural disease.
Interpretation and limitations
NICE supports echo for murmur with symptoms, oedema, abnormal ECG or ejection systolic murmur with reduced second heart sound; urgency rises with exertional syncope or severe symptoms.
04
NT-proBNP for suspected chronic heart failure
Why
Triage specialist assessment and echo.
Interpretation and limitations
Above 2,000 ng/L: specialist assessment and echo within 2 weeks; 400–2,000: within 6 weeks; below 400 in an untreated person makes chronic HF less likely and prompts alternative diagnoses if concern persists.
05
BNP/NT-proBNP in new suspected acute heart failure
Why
Help rule out acute HF and select echo.
Interpretation and limitations
BNP below 100 ng/L or NT-proBNP below 300 ng/L makes acute HF unlikely; if raised, perform echo, considering completion within 48 hours.
06
Chest radiograph, FBC, U&E/eGFR, glucose/HbA1c, lipids, LFT, TFT and troponin as indicated
Why
Evaluate congestion, mimics, precipitants and cardiovascular risk.
Interpretation and limitations
Select rather than shotgun-test: troponin supports myocardial injury but is not specific; normal radiography does not exclude HF or aortic disease.
07
Focused vascular tests
Why
Investigate pulse deficits, bruits, limb symptoms or suspected aortic pathology.
Interpretation and limitations
Use ABPI/Doppler for chronic PAD, emergency vascular imaging for acute limb ischaemia and urgent ECG-gated CTA neck-to-pelvis for suspected AAS.

04Clinical next stepsHow the result changes management or prompts escalation.

01RCUK emergencyUnstable patient or cardiac arrestFirst stepAbnormal responsiveness/breathing, shock, syncope, myocardial ischaemia or severe heart failure associated with arrhythmia.

1Call for help and assess ABCDE with monitoring, IV access and 12-lead ECG without delaying treatment. If unresponsive with abnormal breathing, call 999/resuscitation, start CPR 100–120/min at 5–6 cm and attach AED/defibrillator.
2EscalationRCUK 2025/2026 unstable tachyarrhythmia pathway: synchronised cardioversion—AF at maximum device output; atrial flutter/SVT 70–120 J; VT with pulse 120–150 J, escalating if unsuccessful. Sedate or anaesthetise if conscious when this does not cause harmful delay.
3If cardioversion fails, the RCUK pathway uses expert antiarrhythmic treatment such as procainamide 10–15 mg/kg IV, maximum 1 g, over 20 minutes, or amiodarone 300 mg IV over 10–20 minutes then 900 mg over 24 hours, selected for rhythm and contraindications.
4RCUK adverse-sign bradycardia pathway: atropine 500 micrograms IV, repeated every 3–5 minutes to 3 mg maximum. If ineffective, use transcutaneous pacing and/or isoprenaline 5 micrograms/min or adrenaline 2–10 micrograms/min while arranging expert pacing.

02NICE ACSExamination suggests acute coronary syndromeCurrent/recent ischaemic chest discomfort or equivalent symptoms.

1Obtain a 12-lead ECG as soon as possible, repeat if needed, monitor pulse/BP/rhythm/saturation and activate the appropriate ACS/reperfusion pathway; a normal examination does not justify delay.
2Give aspirin 300 mg orally as soon as possible unless there is true aspirin allergy or active major bleeding.
3For pain, give 1–2 GTN sprays (400–800 micrograms) sublingually initially; if needed, repeat at 5-minute intervals without exceeding 3 sprays total (1.2 mg) in 15 minutes, provided BP is adequate and there is no nitrate contraindication. Give IV opioid analgesia if severe pain persists under monitoring.
4Give oxygen only if saturation is below 94%, targeting 94–98%; target 88–92% if at risk of hypercapnic respiratory failure. Do not use nitrate if AAS is suspected until that pathway is addressed.

03NICE time-defined referralMurmur or syncopeMurmur with symptoms/signs or transient loss of consciousness red flags.

1Offer echocardiography for a murmur with angina/breathlessness, oedema, abnormal ECG, or an ejection systolic murmur plus reduced second heart sound.
2A systolic murmur with exertional syncope warrants urgent specialist/echo assessment; if the presentation was transient loss of consciousness, NICE CG109 red flags require cardiovascular assessment reviewed and prioritised within 24 hours.
3Consider assessment within 2 weeks for a murmur with severe angina/breathlessness at minimal exertion or rest; send acute instability directly to hospital.
4For exercise-induced syncope, arrange exercise testing within 7 days unless severe aortic stenosis or hypertrophic cardiomyopathy is suspected, in which case perform specialist imaging first.

04NICE heart failureCongestion or suspected ventricular dysfunctionRaised JVP, crackles/oedema, displaced apex, S3, orthopnoea or unexplained dyspnoea.

1Acute pulmonary oedema/distress: admit, monitor, obtain ECG/chest imaging/bloods and measure natriuretic peptide; if raised, perform echocardiography, considering completion within 48 hours.
2NICE recommends IV loop diuretic by bolus or infusion for acute heart failure. A dose-naive adult commonly receives furosemide 20–40 mg slow IV; if already taking a loop diuretic, consider at least an equivalent or higher IV dose. Monitor renal function, weight and urine output.
3Do not routinely use opiates or nitrates in acute HF. Consider IV nitrate only for concomitant myocardial ischaemia, severe hypertension, or acute AR/MR, in level-2 care with close BP monitoring.
4Stable suspected chronic HF: NT-proBNP above 2,000 ng/L triggers specialist assessment and echo within 2 weeks; 400–2,000 within 6 weeks.

05Examination sequenceStable complete cardiovascular examinationThe patient is physiologically stable.

1General/end of bed, hands and radial pulse; both-arm BP and standing BP when indicated; face and central cyanosis.
2JVP at 30–45 degrees, carotids separately, then precordial inspection and palpation for apex, heave and thrills.
3Auscultate aortic, pulmonary, tricuspid and mitral areas using diaphragm and bell; describe timing, intensity, pitch, site, radiation and manoeuvre response rather than naming from one feature.
4Examine lung bases, dependent oedema, liver/abdomen and peripheral pulses/limbs; summarise key positive and negative findings, propose differential diagnoses and order focused tests.

05Procedure and medicine safetyRelevant preparation, treatment and contraindications.

Immediate antiplatelet treatment when ACS is suspected.

Aspirin for suspected ACS

300 mg orally as soon as possible, chewed or dispersed when appropriate, unless contraindicated.

True aspirin allergy, active major bleeding and diagnostic concern for AAS require urgent senior judgement; do not delay emergency assessment.

Relieve ischaemic chest pain when haemodynamics permit while definitive ACS care proceeds.

Glyceryl trinitrate sublingual spray

Give 1–2 sprays (400–800 micrograms) sublingually initially; if needed, repeat at 5-minute intervals without exceeding 3 sprays total (1.2 mg) in 15 minutes.

Avoid in severe hypotension/shock, suspected right-ventricular infarction or AAS, severe aortic stenosis and after PDE5 inhibitors; sit/lie the patient down and recheck BP after each dose.

RCUK treatment for bradycardia with adverse signs.

Atropine

500 micrograms IV, repeated every 3–5 minutes to a maximum total 3 mg.

May be ineffective or harmful in heart transplant recipients and may be ineffective in high-grade block with broad QRS; proceed early to pacing/chronotropic infusion and expert help.

RCUK antiarrhythmic option after unsuccessful synchronised shocks in unstable tachyarrhythmia.

Amiodarone after failed cardioversion

300 mg IV over 10–20 minutes, followed by 900 mg IV over 24 hours.

Hypotension, bradycardia, QT prolongation and drug interactions; rhythm-specific choice and administration require monitoring and resuscitation expertise.

NICE-aligned treatment of fluid overload in acute heart failure after clinical assessment.

Furosemide IV

Common dose-naive acute-HF starting dose 20–40 mg by slow IV injection; if already taking a loop diuretic, use at least an equivalent or higher IV dose and titrate to diuresis.

Hypotension, hypovolaemia, renal dysfunction, hypokalaemia/hyponatraemia and ototoxicity with rapid/high-dose administration; monitor weight, urine output, renal function and electrolytes.

06Risks, monitoring and follow-upComplications, safety checks and further assessment.

Repeat ABCDE and observations after every acute intervention; deterioration supersedes completion of the examination.
During GTN, IV diuretic, cardioversion or chronotropic/antiarrhythmic treatment, use continuous ECG and frequent or continuous BP/oxygen-saturation monitoring.
For acute HF diuresis, record urine output, daily weight, fluid balance, renal function and electrolytes.
For a new irregular pulse, document ventricular rate and obtain ECG; ambulatory monitoring duration should match symptom frequency.
When following a murmur, compare symptoms, examination, ECG and serial echo rather than murmur loudness alone.
Document both-arm BP and use the higher arm when a repeat inter-arm difference exceeds 15 mmHg; measure standing BP when indicated.

07Special situationsVariants, exceptions and circumstances that change the usual approach.

Look before you listen

Distress, cyanosis, scars and devices can reveal the urgency and anatomy before the stethoscope is used.

JVP is a pressure sign, not a diagnosis

An elevated JVP suggests raised right-atrial pressure; combine its waveform with lungs, oedema, valve signs and rhythm to identify the cause.

Murmur intensity can deceive

Severe valve disease may be quiet in low flow, while a loud murmur may occur with modest obstruction. Symptoms and echo determine severity.

A pulse is more than a rate

Rhythm directs ECG testing; character suggests stroke volume/valve physiology; delay or asymmetry raises vascular disease—but no single feature is diagnostic.

Exertional syncope is time-critical

With a murmur it raises concern for outflow obstruction. If it was true transient loss of consciousness, NICE requires cardiovascular review prioritised within 24 hours.

Complete means peripheral

Lungs, oedema, abdomen and limb pulses turn isolated auscultation into an assessment of congestion and systemic circulation.

08Common pitfallsFrequent interpretation and management errors.

01
Finishing a ritualised OSCE sequence while the patient is physiologically unstable.
02
Palpating both carotids together or pressing on the carotid sinus.
03
Calling a murmur benign without relating it to symptoms, second heart sound, ECG and echo criteria.
04
Giving oxygen routinely in ACS when saturation is normal.
05
Giving GTN without checking BP, PDE5-inhibitor use, severe aortic stenosis, RV infarction or possible AAS.
06
Treating an irregular pulse as AF without a 12-lead ECG.
07
Using a negative single sign—no crackles, no murmur or equal pulses—to rule out serious disease.