Cardiovascular examination

In the MRCOphth final, you may sometimes be asked to examine the cardiovascular examination. 
The ocular signs that often lead to a request for cardiovascular examination are:
        • pale optic disc from emboli or arteritic ischaemic optic neuropathy
        • emboli in the retinal artery
        • relative afferent pupillary defect
        • homonymous hemi/quadrinopia
        • lens subluxation in Marfan's syndrome
        • thyroid eye disease
You may not be expected to perform the examination to the standard of a physician but you would be 
expected to achieve the standard of a final year medical student. Therefore, it is worth revising 
the steps needed for a complete cardiovascular examination.
Remember that there is no substitute to actually listening to a cardiac murmur in the medical ward.

The most common instructions are:

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A quick checklist for cardiovascular examination 
(the most common signs with ocular association are underlined)

(make sure the patient is fully undressed from the chest up for good observation)

  • shortness of breath
  • pallor
  • cyanosis
  • carotid endarterectomy scar 
    • (the patient may have RAPD or pale optic disc from retinal artery emboli; 
      visual field defect)
  • raised JVP
  • clubbing
  • splinter haemorrhages
  • chest scar from aortic artery repair or valvular replacement.
    • (aortic artery repair or aortic valve replacement in Marfan's syndrome, other 
      valvular replacement notably mitral valve for mitral stenosis is associated with 
      cardiac thrombus and retinal artery embolism)
  • rate and rhythm of the pulse
    • (atrial fibrillation in retinal artery emboli, tachycardia in thyroid eye disease)
  • feel for collapsing pulse
    • (collapsing pulse in aortic incompetence due to Marfan's syndrome)
  • check for any radiofemoral delay
  • feel the apex beat or ventricular lift


  • listen for any mechanical click
    • (cardiac thrombus increases the risk of central or branch retinal artery occlusion)
  • listen for extra heart sounds and murmur (see below)
  • turn the patient to the left for the mitral diastolic murmur 
    • (mitral stenosis increases the risk of cardiac thrombus and again central or branch 
      retinal artery occlusion)
  • lean the patient forward for diastolic murmur in aortic incompetence
    • (Marfan's syndrome with lens dislocation and risk of retinal detachment)
  • do not forget to use the bell to listen for diastolic murmur (see above)
  • listen to the base of the lungs for crepitation.

Further examination:

  • sit the patient's forward and check for sacral oedema
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Examine this patient's pulse.

You may be asked to do this in the medical section of ophthalmology. You are usually asked to do this after 
you have elicited other ocular signs such as central or retinal artery occlusion; pale optic disc; thyroid eye 
disease or subluxated lens. 

When you examine the patient's pulse remember to note the rate, the regularity and the character. This should 
not take more than 45 seconds.

The three most common findings are:

  • The patient has a pulse rate of ___ per minute (take the number of pulse over 15 to 30 seconds and 

  • multiply by 4 or 2 respectively) which is irregular. The patient has atrial fibrillation. Note: digoxin can
    slow down pulse rate and make the irregular pulse less obvious.
  • The patient has a pulse rate of ___ per minute. The patient is tachycardic (if pulse rate is > 100 / minute.

  • Feel the patient's hands for warmth and sweatiness which are common in hyperthyroidism.
  • The patient has a pulse rate of ___ per minute. The pulse has a collapsing character. 
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Listen to this patient's carotid artery.

There is a continuous murmur best heard with the stethoscope placed lateral to the thyroid cartilage (ie. near 
the bifurcation of the carotid artery). Do not confuse the bruit with the ejection systolic murmur arising from the 
aortic stenosis (the ejection murmur in aortic stenosis times in with the heart beat and diminishes as one move the 
stethoscope up the carotid artery).

Other examination:

  • look for embolic phenomenon as in branch or central retinal artery occlusion (but more likely you have 

  • found this sign before being asked to listen for the bruit).
  • examine the opposite neck for any endarterectomy scar.
What are the endarterectomy trials?
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'Examine the cardiovascular system of this patient' or 'Listen to this patient's heart'
(The following heart sounds are the most likely to encounter in the final MRCOphth:


Mitral stenosis

There may be malar flush on the face. The pulse is irregularly irregular (this may be slow suggesting controlled atrial 
fibrillation from digoxin). The patient may have central sternal scar (from open heart surgery) or valvectomy scar (below 
the left breast). The apex beat is not displaced but has a tapping nature. On auscultation there is a loud first heart sound 
and mid-diastolic murmur. The murmur is best heard with the patient lying on her left side and with the bell of the 
stethoscope. The murmur may be preceded by an opening snap.

Other feature:

  • again mention you would like to look for evidence of ocular emboli
  • there may be bruising due to the use of warfarin


What is the main risk of cataract operation in a patient with mitral stenosis?


Mitral incompetence

The patient has atrial fibrillation. There may be mid-sternal scar or valvectomy scar. The apex beat is displaced (mention
how much with reference to the mid-clavicular line and the intercostal spaces). On auscultation, there is a pan-systolic 
murmur with radiation to the axillae.

Other features:

  • listen for associated mid-diastolic murmur as the patient may have mixed mitral stenosis and incompetence
  • look for embolic phenomenon.


Aortic incompetence / aortic root dilatation

The patient has a collapsing pulse. There may be a mid-sternal scar from aortic valve repair. 
On ausculatation, there is an early diastolic murmur (best heard with the patient sitting forward and listen with 
the bell of the stethoscope).

Other feature:

  • this condition is associated with Marfan's syndrome, look for lens subluxation and other features of Marfan's 

  • such as tall stature, kyphoscoliosis, arm span longer than height and high arch palate.


Mechanical heart valve

The pulse may be collapsing (in leaking aortic valve) or in atrial fibrillation (mitral valve replacement). There is a mid-sternal 
scar from open heart surgery. 
In the case of aortic valve replacement, the first heart sound is normal followed by an ejection click, an ejection systolic flow 
murmur and loud click at second heart sound. The second heart sound times with the upstroke of the carotid pulse.
In the case of mitral replacement, there is a loud click in the first heart sound followed by a click in diastole. There may be mid-diastolic flow murmur.

Other findings:

  • clinical signs of embolism (eg. hemiplegia, visual field defect or relative afferent pupillary defect from central retinal 

  • artery occlusion).
  • look for evidence of Marfan's syndrome which is associated with aortic valve dysfunction.

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Palpate this patient's temporal artery.

The patient is likely to have giant cell arteritis.
The temporal artery is prominent and tortuous but there is absent pulsation ( the pulse is best felt just above 
the zygomatic arch). 

Other signs to look for:

  • scar from previous temporal artery biopsy which may be hidden under the hair
  • look for pale optic disc and relative afferent pupillary defect which may suggest arteritic ischaemic 

  • optic neuropathy
  • look for any features of obesity, round face (moon face) and thin skin which suggest that the patient is 

  • on long-term systemic steroid
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