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Basic Cardiac Assessments:  Physical Examination, Electrocardiography, and Chest Radiography

by Gary D. Goldberg, PhD
Clinical Professor of Medical Education
Angeles College of Nursing, Los Angeles, Ca.

ABSTRACT

The human heart is one of the major organs adversely affected by high blood pressure.  Therefore, the registered nurse must provide a careful and thorough evaluation of the assessments needed via the cardiac structure and function (i.e., including visual signs, all non-and invasive cardiac medical devices), which is an obligatory part of the examination of the hypertensive patient.  

Key Points – 

• Hypertensive heart disease can be detected by a clinical examination, ECG, and other cardiac imaging devices.
• Left ventricular hypertrophy (i.e., LVH), may be a manifestation of ‘target organ damage’ and may imply an adverse prognosis from an internal medicine physician or a cardiology clinician for aggressive therapy in the hypertensive patient. 
• The level of systolic and diastolic blood pressure are directly related to coronary artery disease symptoms, both morbidity and mortality.
• The ECG/EKG monitoring system today still remains the “gold standard” method for detecting LVH despite its relative lack of sensitivity. 

Performing the Physical Examination – 

     The persistent and presence of abnormalities on the cardiac and vascular physical examination, preformed by the cardiac nurse or clinician may contribute significantly to the cardiac assessment of the hypertensive patient and to cardiovascular risk stratification as recommended by the Council on High Blood Pressure Research. ¹ The presences of ‘target organ’ damage or clinical cardiovascular disease (e.g., the detection of left ventricular hypertrophy LVH or peripheral vascular disease PVD), may prompt a more aggressive antihypertensive therapy and risk factor modification program for the patient.   

     The most direct association of hypertension (i.e., HTN), with acute (i.e., Ac₃), and chronic coronary syndromes is enhancement or acceleration of the atherosclerotic process in the epicardial coronary vessels.  Add in the contribution of elevated B/P to this formation, progression, and rupture of atherosclerotic plaque is of a major importance.  Within the hypertensive patient, however another mechanism is also at work.  The incidence of a possible silent myocardial ischemic episode is ever present.  As a nurse specialist, you may be working close with the electro physiologist or cardiologist team and key into another important factor, which is in the increased incidence of myocardial ischemia which may result from a supply-demand imbalance within the metabolic demands of the hypertrophied ventricle exceed coronary blood flow.  Therefore, in such an instance, myocardial ischemia or coronary insufficiency may not directly relate to the atherosclerotic process.  Because atherosclerosis is indeed a diffuse process (i.e., disseminate; to spread out), that involves the entire arterial circulation system.  Also, it is possible that atherosclerosis may be a fundamental pathogenetic contributor to the development or maintenance of HTN or other syndromes of excess vaso-reactivity. ²

Risk Factors –

     As part of your assessment strategies, ask your patient if he and/or she has or have had an episode of angina pectoris.  A diffuse pain or discomfort in the chest, which is often described as a tightness or heaviness.  Angina itself is not a disease, but a symptom of heart disease.  Patients experience angina in different ways, but in a given individual the pattern is usually consistent.  The pain is often described as dull rather than sharp, and it typically occurs over a wide area rather than a sharply defined point.  Ask your patient to describe the location of the pain; many people place the whole hand or a clenched fist over the chest instead of pointing to a specific spot. 

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