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 The Art and Science of Cardiac
Physical Examination
with Heart Sounds, Jugular and Precordial Pulsations

2nd Edition
 The Art and Science of Cardiac
Physical Examination
with Heart Sounds, Jugular and Precordial Pulsations

Narasimhan Ranganathan MBBS FRCP(C) FACP FACC FAHA

Associate Professor in Medicine
University of Toronto, Ontario, Canada
Senior Cardiology Consultant
St. Joseph’s Health Centre
Toronto, Ontario, Canada
Vahe Sivaciyan BSc MD FRCP(C)
Assistant Professor in Medicine
University of Toronto, Ontario, Canada
Staff Cardiologist, St. Joseph’s Health Centre
Toronto, Ontario, Canada
Franklin B Saksena MD CM FACP FRCP(C) FACC FAHA
Associate Professor in Medicine
Northwestern University School of Medicine
Chicago, Illinois, USA
Foreword
Sriram Rajagopal MD DM

The Health Sciences Publisher

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© 2016, Jaypee Brothers Medical Publishers
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do not necessarily represent those of editor(s) of the book.
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The Art and Science of Cardiac Physical Examination
Second Edition: 2016
ISBN: 978-93-5152-777-0
Printed at:
 Dedication
Narasimhan Ranganathan, Vahe Sivaciyan and
Franklin B Saksena wish to dedicate this book
to their respective wives, Saroja, Ayda and Kathleen.
For without their support, this book would not
have been possible.
 Foreword
I feel privileged to be asked to write a foreword to this book The Art and
Science of Cardiac Physical Examination.
The authors are very experienced and senior clinicians, and have more
than three decades of rigorous, scientific research into clinical signs and
their mechanisms. They have made seminal contributions to the literature
in this field, particularly in the area of the jugular venous pulse. Further,
they are deeply committed to teaching and communicating the knowledge
and insights that they have acquired over the years.
The past few decades have seen considerable changes in the science
and practice of cardiology. The plethora of new discoveries, new imaging
modalities and newer modes of treatment has tended to overshadow the
importance of sound clinical examination. Indeed, there is a widespread
feeling that both the time and the importance accorded to the formal teach­
ing of clinical skills in many contemporary cardiology training programs
are inadequate. The authors' effort in bringing out this excellent book (and
companion CD) serves as an effective and timely step to correct this trend.
The treatment of the subject matter is comprehensive, with each of
the main chapters starting with a detailed review of the normal physio­
logy underlying a clinical phenomenon as well as the pathophysiology in
different abnormal states, providing a clear understanding of the basis of
the clinical sign. The chapters on the arterial pulse and jugular venous pulse
are particularly illuminative in this respect. The correct technique of elici­
tation of the finding is then lucidly outlined, often with unique methods
to demonstrate phenomena and insightful tips to improve bedside skills.
Finally, the interpretation and integration of the information obtained is
rightly emphasized, so that the finding can be placed in the context of the
larger clinical picture in a cogent and meaningful manner. The summary
at the end of each chapter provides a concise and rapid review to enhance
learning. The chapters are extensively referenced providing rich material for
further learning. The creative and original methods described in the chapter
entitled “Elements of Auscultation” serve to beautifully unify the “Art” and
“Science” aspects of auscultation. A separate chapter on “Pathophysiologic
Basis of Symptoms and Signs in Cardiac Disease” serves to reiterate con­
cepts described elsewhere in the book in the particular context of specific
conditions.
The novel use of audiovisual aids in the companion CD further remark­
ably enhances the value of this book as a learning resource. Examples from
years of clinical observation have been carefully documented and painstak­
ingly converted to video and audio clips that provide an unprecedented
level of realism. The readers are provided with a “clinical experience” where
viii The Art and Science of Cardiac Physical Examination

they can literally see and hear the findings and can verify their skills of
observation and interpretation in a “real-life” setting. This edition introduces
two new chapters on electrocardiography, now widely regarded as part of
the clinical evaluation. The first of these chapters provides extensive cover­
age of the principles of electrocardiography and interpretation, while the
second chapter on “Integration of ECG into the Cardiac Diagnosis” provides
a succinct account of the correlation of ECG findings in a wide range of
cardiac disorders with the pathophysiology of these conditions. The section
on self-assessment is also a valuable educational aid and serves to reinforce
the message on the integration of information from different sources.
This book is bound to be of immense value to any individual interested
in clinical cardiology, from the fresh medical student (who will benefit from
a sound and lucid introduction to the subject) to the senior and experienced
clinician (who will gain new understanding and insight). The companion
CD is well-suited to serve as an important tool for both individual and group
teaching. The authors are to be commended for their extraordinary effort in
distilling decades of clinical experience into this extremely valuable contri­
bution to the important field of clinical cardiology.

Sriram Rajagopal MD DM
Chief Cardiologist
Southern Railway Headquarters Hospital
Chennai, Tamil Nadu, India
 Preface to the 2nd Edition
The first edition of our book was the result of our long-lasting interest in
promoting the usefulness and value of proper cardiac physical examination
in the assessment of cardiac patients. It is a culmination of our long-lasting
experience in teaching and training physicians and students of cardiology.
We have offered a course annually of the same title in Toronto over the last
35 years. Modern technological advances both invasive and non-invasive
have contributed significantly to our knowledge and understanding of car­
diac physical signs and their pathophysiologic correlates. Both students and
the teachers alike become impressed by these technological tools to the
extent of neglecting the age-old art as well as the substantial body of science
behind the cardiac physical examination. These technological advances are
here to stay. However, some have even gone to the extent of suggesting that
a “physician should have an all purpose tool in his or her pocket that would
be more in keeping with the 21st century than the stethoscope, a 200-year-old
technology whose time should be over”.1 One must never forget that any
tool or instrument is only as good as the person using it. The information
that can be derived from the proper assessment of the jugular contours, the
precordial pulsations, the arterial pulses as well as cardiac auscultation can
never be considered waste in terms of the assessment of a cardiac patient,
in our opinion. It is not only cost effective and satisfying and can never be
counterproductive to the patient’s needs. In addition, it could be lifesaving
under certain circumstances (such as in remote locations, during power
failure and times of disaster). Neglect of these basic skills, expected of physi­
cians and cardiologists to be, will not augur well for the future generation
of the physicians and patients alike.
The positive features of our book include among other things innovative
and proven effective teaching methods with the use of recordings of not only
heart sounds and murmurs but also the actual video-recordings of both
normal and abnormal jugular pulsations as well the precordial pulsations
together with arterial flow signals and/or the heart sounds for timing of
the events in relation to the cardiac cycle. We were pleased and not totally
surprised however, when we discovered that our book was translated into
Chinese, a few years ago.2 It suggests also that not all physicians share the
opinion of some who would like to name the stethoscope as “archaic instru­
ment” and lock it up in their office chest. In addition, it indicates a need to
reach out to more medical schools and the institutions in many developed
and developing nations. We are hoping that it would achieve that goal with
our current publishers of this new and improved second edition.
x The Art and Science of Cardiac Physical Examination

In addition to the ‘The Art and Science of Cardiac Physical Examination’,

we have also been interested in teaching 12-lead ECG interpretation to
physicians and trainees for many years offering annual courses. ECG is often
considered an integral part of the office assessment of a cardiac patient
and almost considered to be an extension of cardiac physical assessment.
Most physicians either have or have access to an ECG machine in their
offices. ECG is also indispensable in the assessment of patients presenting
with acute symptoms of chest pain and or dyspnea. Therefore, when we
were faced with the opportunity of providing a second edition, we wanted
to make the book even more comprehensive. In addition to updating new
and relevant information in several of the previous chapters of the first
edition, we have included three new chapters. These consist of the follow­
ing: a complete chapter consisting of six different sections which cover
fully the 12-lead Electrocardiogram Interpretation, a second chapter show­
ing how to integrate the ECG into Cardiac Diagnosis and a third and final
chapter for Self-Assessment at the end with several interesting clinical cases
from our own practice. In addition, we have added a self-assessment sec­
tion in the companion CD with several new clinical examples. We believe
that these self-assessment sections would serve as a good review as well as
being useful for reinforcement purposes both in self-teaching and/or group
learning sessions.
Before we end this preface, we would like to take the opportunity to
reminisce and thank for the friendship and the association we have had
both during the formative years of becoming a cardiologist as well as in the
later years of career as a practicing cardiologist and as a teacher. During
the years of training, I (the senior author) had the opportunity to work
with some of the well-known cardiologists including Dr George E Burch
and Dr John Phillips of the reputed Tulane University medical school as
well as Dr E Douglas Wigle and Dr Malcolm Silver (Cardiac Pathologist)
of the University of Toronto. However, the longest association of teaching
both cardiac physical examination and 12-lead ECG interpretation was with
Dr Jules Constant from the State University of Buffalo, New York, USA. We
in fact used to invite him over to teach along with us in Toronto almost
annually for many years in our annual cardiac physical examination course.
I have also taken part in teaching along with him in ‘the 12-lead ECG inter­
pretation courses’ which he used to organize in the month of February in
the warmer southern climate. He had a fine sense of empathy for the begin­
ners, which was admirable. One’s own teaching technique also becomes
more refined watching other masters perform. In fact, Dr. Constant was
still alive at the time of the release of our first edition of the book. We wish
to list the names of these individuals here in order not only to recognize
their contribution in the field of cardiology but also to express our gratitude.
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