Aortic coarctation physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Physical examination act as an important tool in the diagnosis of coarctation of aorta. In majority of patients with coarctation the constriction is located just distal to the subclavian artery. Due to the presence of constriction at isthmus (proximal to the descencing aorta) the pressure of blood proximal to constriction is high whereas the pressure distal to constriction is low. This leads to hypertension in the upper extremities (supplied by subclavian) and hypotension in lower extremities. The difference is usually in systolic blood pressure whereas the diastolic blood pressures are typically similar. Similarly, the pulses in upper extremities are bounding whereas the femoral pulses are often diminished (brachial-femoral delay

=Vital Signs

Blood Pressure

Differential hypertension - Arterial hypertension in the upper extremity with normal to low blood pressure in the lower extremities is classic.

Pulses

Femoral pulses are often diminished in strength. Exercise exacerbates this gradient.

If the coarctation is situated before the left subclavian artery, the left pulse will be diminished in strength and asynchronous radial pulses will be detected in the right and left arms. A radial-femoral delay between the right arm and the femoral artery may be apparent, while no such delay may be observed with left arm radial-femoral palpation.

A coarctation occurring after the left subclavian artery will produce synchronous radial pulses, but radial-femoral delay will be present under palpation in either arm.

Neck

There may be "webbing" of the neck in patients with Turner syndrome, 10% of whom have aortic coarctation.

Heart

• A systolic ejection click is present when there is an associated bicuspid aortic valve.

• The S2 is loud secondary to hypertension

• An S4 may be present secondary to LVH

• There are 3 potential sources of a murmur: arterial collaterals, an associated bicuspid aortic valve, and the coarctation itself which can be heard over the spine.

• A prominent P2 may be present if there is associated pulmonary hypertension.

Extremities

Cyanosis of the lower extremities may be present.

Occasionally adults may have narrow hips and thin legs or have an undeveloped left arm (in those patients in which the coarctation compromises the origin of the subclavian artery).