Aortic coarctation physical examination

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Aortic coarctation Microchapters


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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]


In the 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). There are 3 potential sources of a murmur: multiple arterial collateral (continuous murmur), an associated bicuspid aortic valve (systolic ejection click), and the coarctation itself which can be heard over the left infraclavicular area and under scapula. Murmurs due to associated cardiac abnormalities such as VSD or aortic valve stenosis, may also be detected. Neonates may present with discrepancies in blood pressure and pulses between the limbs, differential cyanosis or reversed differential cyanosis (depending on associated lesions), murmur, congestive heart failure, and shock. Older children and adolescent may be referred due to agitated behavior, headache, vision problem, and hypertension.

Physical Examination

Appearance of the Patient

  • Tachypnea
  • Labored breathing (prominent accessory muscles)

Vital Signs

Pulses and 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:
    • Tachycardia
    • 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 brachial-femoral delay between the right arm and the femoral artery may be apparent, while no such delay may be observed with left arm brachial-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 brachial-femoral delay can be appreciated.
    • Femoral pulses are often diminished in strength. Exercise exacerbates this gradient.


There may be webbing of the neck in patients with Turner syndrome, 35% of whom have aortic coarctation.




Heart Sounds

Other Presentations



Presentation Based on Age

Neonates (Early Presentation)


Children, Adolescents, and Adults (Late Presentation)

2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines[1]

Diagnostic Recommendations for Coarctation of the Aorta

Class I
1. Resting blood pressure should be measured in upper and lower extremities in all adults with coarctation of the aorta. (Level of Evidence: C-EO)"
Class IIa
1.Ambulatory blood pressure monitoring in adults with coarctation of the aorta can be useful for diagnosis and management of hypertension. (Level of Evidence: C-LD)
Class IIb
1.Exercise testing to evaluate for exercise-induced hypertension may be reasonable in adults with coarctation of the aorta who exercise. (Level of Evidence: C-LD)

2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)[2]

Recommendations for Clinical Evaluation and Follow-Up (DO NOT EDIT)[2]

Class I
"1. Every patient with systemic arterial hypertension should have the brachial and femoral pulses palpated simultaneously to assess timing and amplitude evaluation to search for the brachial-femoral delay of significant aortic coarctation. Supine bilateral arm (brachial artery) blood pressures and prone right or left supine leg (popliteal artery) blood pressures should be measured to search for differential pressure. (Level of Evidence: C)"


  1. Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM; et al. (2019). "2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". J Am Coll Cardiol. 73 (12): 1494–1563. doi:10.1016/j.jacc.2018.08.1028. PMID 30121240.
  2. 2.0 2.1 Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA; et al. (2008). "ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (23): e1–121. doi:10.1016/j.jacc.2008.10.001. PMID 19038677.


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