Pulmonary hypertension physical examination

Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D. [1] ; Assistant Editor(s)-in-Chief: Lisa Prior; Ralph Matar

Pulmonary hypertension (PH) can present with myriad physical findings that may be associated with PH or the underlying cause. Findings associated with pulmonary hypertension are usually connected to right heart failure or right heart overload, while other findings may be associated with underlying cause, such as thoracic deformities which may arise in the setting of COPD, or sclerodactyly that may be seen in patients with scleroderma. Some may develop on a spectrum corresponding to the severity of the disease.

• There are physical examination findings associated with pulmonary hypertension, and other findings associated with the causes for development of pulmonary hypertension.
• Common physical examination findings of pulmonary hypertension include signs of right heart failure such as elevated jugular venous pressure, right ventricular paraesternal heave or subxiphoid thrust, loud P2, right-sided S3 or S4, holosystolic tricuspid regurgitant murmur (that becomes louder after inspiration due to increased venous return), peripheral edema, hepatomegaly, ascites and pulsatile liver.
• Common physical examination findings associated with causes for development of pulmonary hypertension and more specific pulmonary hypertension findings are detailed below:

The appearance of the patient may give clues as to the etiology of the condition. For example in COPD, one of the most common causes of pulmonary hypertension, the patient may appear short of breath with pursed lips breathing and use of accessory muscles. Later on as the disease gets more severe, the patient may appear cyanotic with extremities cold to the touch.^[1]

The pulse may be diminished. This usually occurs in more severe cases.^[1]

• Telangiectasia: suggestive of scleroderma
• Digital ulceration: suggestive of scleroderma
• Sclerodactyly: suggestive of scleroderma
• Spider nevi: suggestive of liver disease
• Palmar erythema: suggestive of liver disease
• Clubbing: may be indicative of congenital heart disease or pulmonary veno-occlusive disease^[2]

Assessment of the JVP in pulmonary hypertension involves assessing the ‘a’ wave (coincides with atrial contraction), the ‘v’ wave (coincides with atrial filling) and the height of the JVP column above the sternal angle. Physical findings may include:

• Prominent ‘a’ wave: due to forced atrial contraction
• Prominent ‘v’ wave: later if tricuspid regurgitation develops with right ventricular failure
• Elevated JVP: can be present if right ventricular failure develops
• Postive Kussmaul’s sign: JVP elevation during inspiration (the opposite of what normally happens) because of right ventricular failure^[1]
• Positive abdominojugular reflux: JVP rises and remains elevated during a period of over 10 seconds whilst abdominal pressure is applied. This may be present if right ventricular failure develops.^[1]

• Lung exam is generally normal.
• Crackles upon inspirations are indicative of interstitial lung disease.

A complete precordial assessment of pulmonary hypertension involves palpating the precordium for heaves and thrills and auscultating to assess first and second heart sounds, splitting of the second heart sound and determining if there are any added heart sounds or murmurs. Physical findings may include the following:

• Left parasternal heave: due to hyperdynamic right ventricle
• Palpable P2: correlates with severe disease ^[1]

• Loud P2 component of S2: this is due to the forceful closure of the valve because of increased pulmonary pressure. It can be heard mostly in the pulmonary area (upper right sternal border). If it is evident at the cardiac apex, this indicates more severe disease. It is best appreciated on inspiration.^[3]

• Narrowed splitting of S2: in chronic pulmonary hypertension, pulmonary artery compliance decreases leading to earlier pulmonary valve closure and narrowed splitting.^[4]
• Widened splitting of S2: widened splitting may occur later if right ventricular failure or bundle branch block develops.^[3]

• S4: due to right ventricular hypertrophy and therefore reduced compliance secondary to pulmonary hypertension. It is increased with inspiration.
• S3: if right ventricular failure develops. Increased with inspiration.^[1]

• Systolic pulmonary ejection click: increased with inspiration

• Ejection midsystolic murmur: increased with inspiration
• Diastolic murmur (Graham-Steele murmur): indicates pulmonary regurgitation
• Pansystolic murmur: indicates tricuspid regurgitation and developing right ventricular failure^[5]

Findings in the abdomen include:

• Ascites: indicates right ventricular failure
• Painful hepatomegaly: indicates right ventricular failure
• Pulsatile liver: due to tricuspid regurgitation ^[1]

• Edema: indicates right ventricular failure^[1]
• Cool extremities: indicates severe disease

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