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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

The cardiovascular examination

Cardiology · UK scope · Sources checked 25 Aug 2026 · Clinical review pending

RapidFull
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Escalate

Stop the routine examination and use ABCDE if the patient has abnormal responsiveness/breathing, shock, ongoing ischaemic chest pain, severe respiratory distress/pulmonary oedema, new cyanosis, an unstable arrhythmia or an acutely ischaemic limb. If unresponsive with abnormal breathing, call 999/resuscitation, start CPR at 100–120 compressions/min to 5–6 cm depth and attach an AED/defibrillator as soon as possible.

Synopsis

Perform a safe, reproducible adult cardiovascular examination, link findings to focused investigations and recognise signs that require immediate or time-defined escalation.

  • 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.

Key red flags

Shock or peri-arrest physiology

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 syndrome

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 arrhythmia

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

Valve red flags

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 failure

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 emergency

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.

Investigation priorities

01
12-lead ECG within the acute pathwayFirst step

Assess chest pain, dyspnoea, syncope, irregular pulse, brady/tachycardia and suspected structural disease.

Management branches

RCUK emergencyUnstable patient or cardiac arrest

Abnormal responsiveness/breathing, shock, syncope, myocardial ischaemia or severe heart failure associated with arrhythmia.

  1. Call 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.
  2. RCUK 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.
  3. If 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.
  4. RCUK 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.
Examination sequenceStable complete cardiovascular examination

The patient is physiologically stable.

Key medicines

Aspirin for suspected ACS300 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.
Glyceryl trinitrate sublingual sprayGive 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.
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Sources and review status11 sources · checked 25 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 25 Aug 2026; clinical approval remains outstanding.

  • Resuscitation Council UK 2025: First aid guidelinesABCDE and early escalation.
  • Resuscitation Council UK 2025: Adult basic life support
  • Resuscitation Council UK 2025: Adult advanced life supportOfficial RCUK 2025 peri-arrest arrhythmia doses and shock energies; protocol-dependent.
  • NICE NG196: Atrial fibrillation—recommendations
  • NICE NG208: Heart valve disease—recommendations
  • NICE NG106: Chronic heart failure—recommendations
  • NICE CG187: Acute heart failure—recommendations
  • NICE NG185: Acute coronary syndromes—recommendations
  • NICE CG109: Transient loss of consciousness—recommendations
  • NICE NG136: Hypertension in adults—BP measurement
  • Glyceryl trinitrate spray SmPC

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
  1. General/end of bed, hands and radial pulse; both-arm BP and standing BP when indicated; face and central cyanosis.
  2. JVP at 30–45 degrees, carotids separately, then precordial inspection and palpation for apex, heave and thrills.
  3. Auscultate 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.
  4. Examine lung bases, dependent oedema, liver/abdomen and peripheral pulses/limbs; summarise key positive and negative findings, propose differential diagnoses and order focused tests.