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[[Image:Pulmonary_hypertension_physical_exam.png|thumb|200px|right|Physical exam findings in Pulmonary hypertension and right ventricular failure]]
__NOTOC__
{{Pulmonary hypertension}}
'''Editor(s)-in-Chief:''' [[User:C Michael Gibson |C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com] ; '''Assistant Editor(s)-in-Chief:''' [[User:Lisa Prior|Lisa Prior]]; [[User:Ralph Matar|Ralph Matar]]
 
==Overview==
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.


{{Pulmonary hypertension}}
==Physical Examination==


'''Editor(s)-in-Chief:''' [[User:C Michael Gibson |C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org] Phone:617-632-7753; '''Assistant Editor(s)-in-Chief:''' [[User:Lisa Prior|Lisa Prior]],[[User:Ralph Matar|Ralph Matar]],  
*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:


==Overview==
===General Appearance===  
*[[Physical examination]] is performed to look for typical signs of pulmonary hypertension.


*Pulmonary hypertension can present with a myriad of physical signs that develop on a spectrum corresponding to the severity of the disease.
The appearance of the patient may give clues as to the etiology of the condition. For example in [[Chronic obstructive pulmonary disease|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 [[cyanosis|cyanotic]] with extremities cold to the touch.<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>


*The condition is often initially associated with a '''loud P2''', '''(para)sternal heave''', and '''narrowed splitting of the second heart sound''' on physical examination. S<sub>3</sub> or third heart sound, and pulmonary regurgitation may also be heard on auscultation.
===Pulse===


*As pulmonary hypertension worsens, right ventricular failure can develop, which can present with findings such as '''increased JVP''', '''ascites''' and '''peripheral edema''', [[Abdominojugular test|hepatojugular reflux]], and [[clubbing]].  
The [[Pulse|pulse]] may be diminished. This usually occurs in more severe cases.<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
*Physical examination evidence of [[tricuspid insufficiency]] is also sought and, if present, is consistent with the presence of long-standing pulmonary hypertension.


A more comprehensive discussion on physical findings is discussed in the sections below categorised by examination site
===Skin===
* [[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]]<ref name="pmid19713419">{{cite journal| author=Galiè N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA et al.| title=Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). | journal=Eur Heart J | year= 2009 | volume= 30 | issue= 20 | pages= 2493-537 | pmid=19713419 | doi=10.1093/eurheartj/ehp297 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19713419  }} </ref>


==General appearance==  
===Jugular Venous Pressure - JVP===  


The appearance of the patient may give clues as to the etiology of the condition.
Assessment of the [[Jugular venous pressure|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:
For example in [[Chronic obstructive pulmonary disease|COPD]], one of the most common causes of pulmonary hypertension, the patient may appear dyspneic with pursed lips breathing and use of accessory muscles.
Later on in severe disease, the patient may appear [[cyanosis|cyanotic]] with extremities cold to the touch. <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>


==Pulse==  
* Prominent 'a' wave: due to forced atrial contraction
* Prominent 'v' wave: later if [[Tricuspid regurgitation|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]]<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
* Positive [[Hepatojugular reflux|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.<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>


The [[Pulse|pulse]] may be low volume. This usually occurs in more severe disease. <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
===Lungs===
* [[Lung]] exam is generally normal.
* [[Crackles]] upon inspirations are indicative of [[interstitial lung disease]].


==JVP==  
===Cardiovascular===


Assessment of the [[Jugular venous pressure|JVP]] in pulmonary hypertension involves assessing the 'a' wave (coincides with atrial contraction), the 'v' wave (coincides with atrial
A complete [[precordium|precordial]] assessment of pulmonary hypertension involves [[Palpation of the precordium|palpating the precordium]] for [[Heave|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|heart sounds]] or murmurs. Physical findings may include the following:
filling) and the height of the JVP column above the sternal angle. Physical findings may include:


*'''Prominent 'a' wave''': due to forced atrial contraction
====Palpation====
*'''Prominent 'v' wave''': later if [[Tricuspid regurgitation|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 <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
*'''Positive [[Hepatojugular reflux|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 <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>


==Precordium==
* Left parasternal heave: due to hyperdynamic [[right ventricle]]
* Palpable P2: correlates with severe disease <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>


An holistic [[precordium|precordial]] assessment of pulmonary hypertension involves [[Palpation of the precordium|palpating the precordium]] for [[Heave|heaves]] and thrills and ausculatating to assess first
====Auscultation====
and second heart sounds, splitting of the second heart sound and determining if there any added [[Heart sounds|heart sounds]] or murmurs. Physical findings may include the
following:


===Palpation===
=====First and second heart sound (S1,S2)=====


*'''Parasternal heave''': due to hyperdynamic right ventricle
* 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.<ref name="isbn0-7817-7012-2">{{cite book |author=Thompson, Paul Richard; Topol, Eric J.; Califf, Robert M.; Prystowsky, Eric N.; Thomas, James Alan |title=Textbook of cardiovascular medicine |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2007 |pages= |isbn=0-7817-7012-2 |oclc= |doi= |accessdate=}}</ref>
*'''Palpable P2''': correlates with severe disease <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>


===Ausculation===  
=====Splitting of S2=====


====First and second heart sound (S1,S2) assessment====
* Narrowed splitting of S2: in chronic pulmonary hypertension, pulmonary artery compliance decreases leading to earlier pulmonary valve closure and narrowed splitting.<ref name="isbn0-07-055417-X">{{cite book |author=Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. |title=The Heart, arteries and veins |publisher=McGraw-Hill, Health Professions Division |location=New York |year=1994 |pages= |isbn=0-07-055417-X |oclc= |doi= |accessdate=}}</ref>
* Widened splitting of S2: widened splitting may occur later if right ventricular failure or bundle branch block develops.<ref name="isbn0-7817-7012-2">{{cite book |author=Thompson, Paul Richard; Topol, Eric J.; Califf, Robert M.; Prystowsky, Eric N.; Thomas, James Alan |title=Textbook of cardiovascular medicine |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2007 |pages= |isbn=0-7817-7012-2 |oclc= |doi= |accessdate=}}</ref>


*'''Loud P2 component of S2''': this is due to forceful closure of the valve because of increased pulmonary pressure. It can be heard mostly in 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. <ref name="isbn0-7817-7012-2">{{cite book |author=Thompson, Paul Richard; Topol, Eric J.; Califf, Robert M.; Prystowsky, Eric N.; Thomas, James Alan |title=Textbook of cardiovascular medicine |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2007 |pages= |isbn=0-7817-7012-2 |oclc= |doi= |accessdate=}}</ref>
=====Extra Heart Sounds=====
* 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.<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>


====Splitting of S2 assessment====  
=====Additional Sounds=====
* Systolic pulmonary ejection click: increased with inspiration


*'''Narrowed splitting of S2''': in chronic pulmonary hypertension, pulmonary artery compliance decreases leading to earlier pulmonary valve closure and narrowed splitting. <ref name="isbn0-07-055417-X">{{cite book |author=Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. |title=The Heart, arteries and veins |publisher=McGraw-Hill, Health Professions Division |location=New York |year=1994 |pages= |isbn=0-07-055417-X |oclc= |doi= |accessdate=}}</ref>
=====Murmurs=====  
*'''Widened splitting of S2''': widened splitting may occur later if right ventricular failure or bundle branch block develops. <ref name="isbn0-7817-7012-2">{{cite book |author=Thompson, Paul Richard; Topol, Eric J.; Califf, Robert M.; Prystowsky, Eric N.; Thomas, James Alan |title=Textbook of cardiovascular medicine |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2007 |pages= |isbn=0-7817-7012-2 |oclc= |doi= |accessdate=}}</ref>
* Ejection midsystolic murmur: increased with [[inspiration]]
* Diastolic murmur (Graham-Steele murmur): indicates [[pulmonary regurgitation]]
====Extra heart sounds assessment====
* Pansystolic murmur: indicates [[tricuspid regurgitation]] and developing [[right ventricular failure]]<ref name="isbn0-7020-2993-9">{{cite book |author=Clark, Michael; Kumar, Parveen J. |title=Kumar and Clark's clinical medicine |publisher=Elsevier Saunders |location=St. Louis, Mo |year=2009 |pages= |isbn=0-7020-2993-9 |oclc= |doi= |accessdate=}}</ref>
*'''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. <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
====Additional sounds assessment====
*'''Systolic pulmonary ejection click''': increased with inspiration


====Murmurs assessment====
===Abdomen===  
*'''Ejection midsystolic pulmonic murmur''': increased with inspiration
*'''Diastolic pulmonary regurgitation murmur (Graham-Steele murmur)''': indicates more severe disease
*'''Pansystolic tricuspuid regurgitation murmur''': indicates developing right ventricular failure <ref name="isbn0-7020-2993-9">{{cite book |author=Clark, Michael; Kumar, Parveen J. |title=Kumar and Clark's clinical medicine |publisher=Elsevier Saunders |location=St. Louis, Mo |year=2009 |pages= |isbn=0-7020-2993-9 |oclc= |doi= |accessdate=}}</ref>
 
==Abdomen==  


Findings in the abdomen include:
Findings in the abdomen include:


*'''[[Ascites]]''': indicates right ventricular failure
* [[Ascites]]: indicates right ventricular failure
*'''Painful [[hepatomegaly]]''': indicates right ventricular failure
* Painful [[hepatomegaly]]: indicates right ventricular failure
*'''Pulsatile liver''': due to tricuspid regurgitation <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
* Pulsatile liver: due to tricuspid regurgitation <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>


==Legs==  
===Extremities===  


*'''[[Edema]]''': indicates right ventricular failure <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
* [[Edema]]: indicates [[right ventricular failure]]<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
* [[Cool extremities]]: indicates severe disease


==References==
==References==
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Latest revision as of 17:10, 9 June 2021

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

Overview

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.

Physical Examination

General Appearance

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]

Pulse

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

Skin

Jugular Venous Pressure - JVP

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:

Lungs

Cardiovascular

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:

Palpation

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

Auscultation

First and second heart sound (S1,S2)
  • 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]
Splitting of S2
  • 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]
Extra Heart Sounds
  • 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]
Additional Sounds
  • Systolic pulmonary ejection click: increased with inspiration
Murmurs

Abdomen

Findings in the abdomen include:

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

Extremities

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP (2009). Clinical Examination: A Systematic Guide to Physical Diagnosis. Edinburgh: Churchill Livingstone. ISBN 0-7295-3905-9.
  2. ↑ Galiè N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA; et al. (2009). "Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT)". Eur Heart J. 30 (20): 2493–537. doi:10.1093/eurheartj/ehp297. PMID 19713419.
  3. ↑ 3.0 3.1 Thompson, Paul Richard; Topol, Eric J.; Califf, Robert M.; Prystowsky, Eric N.; Thomas, James Alan (2007). Textbook of cardiovascular medicine. Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-7012-2.
  4. ↑ Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. (1994). The Heart, arteries and veins. New York: McGraw-Hill, Health Professions Division. ISBN 0-07-055417-X.
  5. ↑ Clark, Michael; Kumar, Parveen J. (2009). Kumar and Clark's clinical medicine. St. Louis, Mo: Elsevier Saunders. ISBN 0-7020-2993-9.

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