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Cardio Exam

The Nails

July 1st, 2020


In the context of the cardiovascular examination, inspection of the nails can aid in identifying evidence of anaemia, cyanosis and endocarditis.

Pallor of the Nail Bed

  • Look For

  • Whitening of the nail beds.
  • Causes of Nail Bed Pallor

  • Anaemia
  • Low cardiac output, due to cardiac disease
  • Peripheral shutdown, due to increased sympathetic activity.

Nail Bed Cyanosis

  • Look For

  • Blue discolouration of the nail beds
  • Significance

  • Nail bed cyanosis is a type of peripheral cyanosis, characterised by elevated levels of deoxygenated haemoglobin (hypoxaemia) in the peripheries. Always look for central cyanosis (under the tongue) when this is present.
  • Causes of Nail Bed Cyanosis

  • Central Cyanosis

  • High altitude
  • Obstructive lung disease, pulmonary oedema, pneumonia, pulmonary embolism
  • Congenital heart disease
  • Methaemoglobinaemia / sulfhaemoglobinaemia / carboxyhaemoglobinaemia
  • Peripheral Cyanosis

  • As for central cyanosis
  • Reduced cardiac output
  • Vasoconstriction

Splinter Haemorrhages

  • Look For

  • Painless, longitudinal, non-blanching red-brown streaks of 1-3mm in length beneath the fingernails or toenails.
  • Significance

  • A sign of infective endocarditis, though may also be caused by trauma, drugs or certain types of vasculitis.
  • Causes of Splinter Haemorrhages

  • Nail bed trauma
  • Infective endocarditis
  • Vasculitis - antiphospholipid syndrome, SLE, Behcet's disease, rheumatoid vasculitis
  • Skin conditions - psoriasis, lichen planus
  • Drugs - sunitinib, sorafenib
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