Clinical Review State of the Art Review

How valuable is physical examination of the cardiovascular system?

BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3309 (Published 27 July 2016) Cite this as: BMJ 2016;354:i3309
  1. Andrew Elder, professor1,
  2. Alan Japp, consultant cardiologist2,
  3. Abraham Verghese, professor3
  1. 1Department of Geriatric Medicine, Edinburgh Medical School, Edinburgh, UK
  2. 2Department of Cardiology, Edinburgh Medical School, Edinburgh, UK
  3. 3Department of Medicine, Stanford University, Palo Alto, CA, USA
  1. Correspondence to: A T Elder, Department of Acute Medicine of Older Age, Western General Hospital, Edinburgh EH4 2XU, UK atelder{at}gmail.com

Abstract

Physical examination of the cardiovascular system is central to contemporary teaching and practice in clinical medicine. Evidence about its value focuses on its diagnostic accuracy and varies widely in methodological quality and statistical power. This makes collation, analysis, and understanding of results difficult and limits their application to daily clinical practice. Specific factors affecting interpretation and clinical application include poor standardisation of observers’ technique and training, the study of single signs rather than multiple signs or signs in combination with symptoms, and the tendency to compare physical examination directly with technological aids to diagnosis rather than explore diagnostic strategies that combine both. Other potential aspects of the value of physical examination, such as cost effectiveness or patients’ perceptions, are poorly studied. This review summarises the evidence for the clinical value of physical examination of the cardiovascular system. The best was judged to relate to the detection and evaluation of valvular heart disease, the diagnosis and treatment of heart failure, the jugular venous pulse in the assessment of central venous pressure, and the detection of atrial fibrillation, peripheral arterial disease, impaired perfusion, and aortic and carotid disease. Although technological aids to diagnosis are likely to become even more widely available at the point of care, the evidence suggests that further research into the value of physical examination of the cardiovascular system is needed, particularly in low resource settings and as a potential means of limiting inappropriate overuse of technological aids to diagnosis.

Footnotes

  • We could not have completed this review without the existing published work and helpful comments of Steven McGee (Seattle). We thank Stuart Shaw (Edinburgh) and Junaid Zaman (Stanford) for their comments and Estela Dukan (Edinburgh) for helping with the literature search.

  • Contributors: AE, AJ, and AV all contributed to the creation of the outline and drafts of the paper. AE and AJ led the literature review. AE is the guarantor.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • Patient involvement: No patients were asked for input in the creation of this article.

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