Aortic coarctation physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S.[2], Cafer Zorkun, M.D., Ph.D. [3]; Assistant Editor(s)-In-Chief: Kristin Feeney, B.S.[4]

Overview

Physical examination acts 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)

Physical Examination

Vital Signs

Pulses & Blood Pressure

• In human anatomy, the subclavian arteries are two major arteries of the upper thorax. They receive blood from the arch of the aorta. The left subclavian artery supplies blood to the left arm and the right subclavian artery supplies blood to the right arm, with some branches supplying the head and thorax.
• Abnormalities in blood pressure and pulses are hallmark of diagnosis in coarctation of aorta.The physical finding depends on the severity and location of constriction relative to the the origin of subclavian artery:
  • Left subclavian proximal to coarctation - Hypertension and normal pulses in both arms and hypotension and diminished pulses in lower extremities (differential hypertension). Synchronous radial pulses, but radial-femoral delay will be present under palpation in either arm. This may be appreciated best by simultaneous arm and leg pulse palpation.
  • Left subclavian distal to coarctation - Hypotension and diminished pulses in left arm and lower extremities. 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.
  • Both right and left subclavian artery originate below coarctation - Blood pressure and pulses decreased in all four extremities.
  • In mild cases though the pulses are palpable in all for extremities a brachio femoral delay can be appreciated.
  • Femoral pulses are often diminished in strength. Exercise exacerbates this gradient.

General physical examination

Neck

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

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).

Cardiovascular

• 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.

Presentation based on age

Neonates

Vitals

• Tachypnea
• Labored breathing (prominent accessory muscles)
• Tachycardia
• Reduced or absent lower limb pulses (femoral)
• Differential hypertension (ususally upper extremities have high blood pressure and lower extremities low)

General physical examination

• Differential cyanosis (pink upper extremities with cyanotic lower extremities) may occur when right-to-left shunt across a patent ductus arteriosus provides flow to the lower body.
• Reversed differential cyanosis (upper body cyanosis with normal lower-body oxygen) may occur with associated lesions like transposition of the great arteries, patent ductus arteriosus, and pulmonary hypertension (right-to-left ductal shunting)

Cardiovascular

• Congestive heart failure (may present as tachycardia, tachypnea, ankle edema, anasarca, jugular vein distention, pleural effusion with dullness to percussion at the bases, rales, hepatomegaly, ascites, S3gallop rhythm, displaced point of maximum impulse (PMI) consistent with an enlarged left ventricle)
• Shock