CARDIOVASCULAR REVIEW

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CARDIOVASCULAR REVIEW
R. MICHAEL RODRIGUEZ, M.D. ASSOCIATE PROFESSOR OF
MEDICINE VANDERBILT UNIVERSITY SCHOOL OF MEDICINE
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THE BLOOD PRESSURE

• THE CUFF SHOULD BE PLACED I INCH ABOVE THE
  ANTECUBITAL SPACE
• LISTEN WITH THE DIAPHRAGM OF THE SCOPE
• THE WIDTH OF THE CUFF SHOULD BE AT LEAST 40 OF
  THE CIRCUMFERENCE OF THE LIMB USED
• NL CUFF IN OBESE PATIENT LEADS TO OVERESTIMATION
  OF BP
• AVOID CAFFEINE, SMOKING, EXERCISE AND EATING AT
  LEAST ½ HOUR BEFORE MEASUREMENT
• EXAM BP IN BOTH ARMS - A DIFFERENCE OF gt 10 MMHG
  IN THE SYSTOLIC PRESSURE IS ABNORMAL AND
  SUGGESTS OBSTRUCTION
• SYSTOLIC BP IN LEGS MAY BE 20 MMHG HIGHER THAN IN
  THE ARMS BUT DIASTOLIC IS USUALLY THE SAME
• HILLS SIGN SYSTOLIC PRESSURE IN THE POPLITEAL
  ARTERY IS GREATER THAN 20MMHG THAT IN THE
  BRACHIAL (AI)

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HISTORY OF THE ARTERIAL PULSE

• PTOLEMAIC ALEXANDRIA 3-4TH CENTURY B.C.
  HEROPHILUS FIRST TO SUGGEST THE VALUE OF THE
  PULSE
• CHINESE 1000 YEARS LATER - FOUR PULSATIONS PER
  RESPIRATION
• JOHN FLOYER 18TH CENTURY USED SECOND HAND ON A
  WATCH TO COUNT THE PULSE FOR ONE MINUTE PUBLISHED
  THE PHYSICIANS PULSE WATCH 1707
• NOT UNTIL 19TH CENTURY DID TIMING THE PULSE
  BECOME THE STANDARD OF CARE.

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THE NORMAL ARTERIAL PULSE
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THE ARTERIAL PULSE
NOTE STEEPER UPSTROKE, HIGHER SYSTOLIC PEAK AS
PULSE IS TRANSMITTED TO THE PERIPHERY USE CENTRAL
VESSELS TO FEEL FOR THE CONTOUR OF THE PULSE
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ABNORMALITIES OF THE ARTERIAL PULSE
AORTIC STENOSIS
AORTIC REGURGITATION
AORTIC REGURGITATION
CONGESTIVE HEART FAILURE
CARDIAC TAMPONADE
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WHICH ARTERIES SHOULD WE USE TO EVALUATE THE
PULSE?
RADIAL - RATE AND RHYTHM CAROTID OR BRACHIAL -
CONTOUR
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THE CENTRAL VENOUS PRESSURE
A WAVE- ATRIAL CONTRACTON C WAVE- BULGING OF
TRICUSPID VALVE X DESCENT- ATRIAL RELAXATION V
WAVE-CLOSURE OF TRICUSPID VALVE WITH ATRIAL
DISTENSION Y DESCENT- OPENING OF THE TRICUSPID
VALVE
JAMA 1996275630-634
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EXAMINATION OF THE NECK VEINS
POSITION DISTINGUISH BETWEEN ARTERIAL AND VENOUS
PULSE ESTIMATE CVP CVPJVP5 ABDOMINOJUGULAR
REFLUX TEST (HEPATOJUGULAR)
AHA EXAMINATION OF THE HEART PART 2
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DISTINGUISHING CAROTID ARTERIAL AND JUGULAR
VENOUS WAVE FORMS
JAMA 1996275630-634
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ABNORMALITIES IN THE VENOUS WAVEFORM
JAMA 1996275630-634
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CANNON A WAVE
AHA EXAMINATION OF THE HEART PART 2
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MANEUVERS TO DIFFERENTIATE SYSTOLIC MURMURS

• RESPIRATORY
• THOSE WHICH AFFECT VENOUS RETURN
• VALSALVA
• SQUATTING TO STANDING
• STANDING TO SQUATTING
• PASSIVE LEG ELEVATION
• THOSE WHICH AFFECT SYSTEMIC
• VASCULAR RESISTANCE
• ISOMETRIC HAND GRIP
• AMYL NITRITE (NO LONGER USED BUT WORTH
• KNOWING)

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RESPIRATION

• INSPIRATION WILL INCREASE THE VENOUS RETURN TO
  THE RIGHT HEART
• INSPIRATION DECREASES VENOUS RETURN TO THE LEFT
  HEART
• MURMURS ON THE RIGHT SIDE OF THE HEART WILL
  INTENSIFY (TR CARVALLOS SIGN) WHILE THOSE ON
  THE LEFT WILL GENERALLY DECREASE

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VENOUS RETURN

• DECREASED WITH VALSALVA AND SQUATTING TO STANDING
  - HOCM IS LOUDER
• INCREASED WITH STANDING TO SQUATTING AND PASSIVE
  LEG ELEVATION - HOCM IS SOFTER

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SYSTEMIC VASCULAR RESISTANCE (AFTERLOAD)

• THE ISOMETRIC HAND GRIP MANEUVER INCREASES
  AFTERLOAD THIS WILL INCREASE THE MURMUR OF MR
  AND A VSD
• AMYL NITRITE REDUCES AFTERLOAD THIS WILL
  DECREASE THE ABOVE MURMURS

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VALSALVA MANEUVER

• ANTONIO VALSALVA (1666-1723) FIRST USED TO
  INFLATE AND CLEAN THE EUSTACHIAN TUBE
• THE MANEUVER RESULTS IN CHANGES IN INTRATHORACIC
  PRESSURE AND VENOUS RETURN
• TWO PHASES STRAIN AND RELEASE
• STRAIN PHASE - BEAR DOWN INCREASE
  INTRATHORACIC PRESSURE DECREASE VENOUS
  RETURN DECREASED LEFT VENTRICULAR
  VOLUME
• RELEASE PHASE QUIT BEARING DOWN - HAS THE
  OPPOSITE EFFECT
• DURING THE STRAIN PHASE TWO MURMURS BECOME LOUDER
  HOCM AND MVP(MVP SOME AUTHORS FEEL THAT THE
  CLICK IS AFFECTED AND NOT THE INTENSITY OF THE
  MURMUR, MOVING THE CLICK CLOSER TO S1), MOST
  OTHER MURMURS BECOME SOFTER

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CLASS NOTES
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THE BASIC HEART SOUNDS
BRAUNWALD E.HEART DISEASE 1994 29
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THE FIRST HEART SOUND
AHA EXAMINATION OF THE HEART PART 4
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NORMAL AND ABNORMAL 2ND HEART SOUNDS
AHA EXAMINATION OF THE HEART PART 4
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THE 3RD HEART SOUND

• VENTRICULAR ORIGIN - FROM RAPID DIASTOLIC FILLING
• EARLY DIASTOLE
• BELL
• KENTUCKY - (CADENCE)
• gt 40 YO ABNORMAL
• lt 40 YO MAY BE NORMAL
• CONGESTIVE HEART FAILURE OR VALVULAR DISEASE

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THE 4TH HEART SOUND

• VENTRICULAR ORIGIN - RAPID DIASTOLIC FILLING
• LATE DIASTOLE
• HYPERTROPHY OR FIBROTIC VENTRICLE
• BELL
• TENNESSEE - (CADENCE)
• REQUIRES ATRIAL KICK DISAPPEARS IN PATIENTS WITH
  A FIB
• AORTIC STENOSIS, HYPERTROPHIC CARDIOMYOPATHY,
  HYPERTENSION

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AHA EXAMINATION OF THE HEART PART 4
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CONGESTIVE HEART FAILURE

• SYMPTOMS
• DYSPNEA
• PND
• ORTHOPNEA
• PALPITATIONS
• CHEST PAIN
• NAUSEA (MI)
• VOMITTING (MI)
• DIAPHORESIS(MI)
• INCREASED ABDOMINAL GIRTH
• DECREASED EXERCISE TOLERANCE

• PHYSICAL FINDINGS
• JVD
• S3
• DISPLACED PMI
• MURMURS SYSTOLIC AND DIASTOLIC
• EDEMA
• WHEEZES
• CRACKLES (FINE LATE INSPIRATORY)
• IRREGULAR PULSE

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SYSTOLIC MURMURS
JAMA 1997277564-571
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LOCATION OF SYSTOLIC MURMURS
JAMA 1997277564-571
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HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY (HOCM)
STANDING
SQUATTING
PHYSICAL FINDINGS MURMUR MAY BE
HARSH LLSB MANEUVERS
DM 199452-112
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AORTIC INSUFFICIENCY
TRADITIONAL PHYSICAL FINDINGS DIASTOLIC
MURMUR DILATED APICAL IMPULSE FORECEFUL AND
COLLAPSING PULSES (EPONYMS) TO AN FRO MURMUR WHEN
PRESENT WITH AN AORTIC FLOW MURMUR AUSTIN FLINT
MURMUR - AN APICAL DIASTOLIC MURMUR WHICH MAY
RESEMBLE MS HILLS TEST WIDE PULSE PRESSURE
DM 199452-112
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MITRAL REGURGITATION
PHYSICAL FINDINGS HOLOSYSTOLIC MURMUR
SHORT MURMUR LLSB RADIATES TO THE
AXILLA ELEVATED JVP IRREGULAR
PULSE REGULAR
PULSE
DM 199452-112
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MITRAL STENOSIS
PHYSICAL FINDINGS MID DIASTOLIC MURMUR BELL
LLDP LOUD FIRST HEART SOUND OPENING SNAP SMALL OR
ABSENT APICAL IMPULSE
DM 1994 52-112
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MITRAL REGURGITATION AND AORTIC STENOSIS
PHYSICAL FINDINGS AS SYSTOLIC MURMUR RADIATES TO
THE NECK PULSUS PARVUS ET TARDUS DECREASED
INTENSITY OF SECOND HEART SOUND
DM 199452-112
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TRICUSPID REGURGITATION
PHYSICAL FINDINGS INCREASED WITH INSPIRATION
(CARVALLOS SIGN) JVD PULSATILE LIVER - ?ASCITES
JAMA 1997277564-571
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MITRAL VALVE PROLAPSE BARLOW SYNDROME
PHYSICAL FINDINGS RESPONSIVE TO MANEUVERS CLICK
MID TO LATE SYSTOLE (NOTE INTENSITY OF THE MURMUR
DEPENDS MORE ON AFTERLOAD)
AHA EXAMINATION OF THE HEART PART 4
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TIMING AND LOCATION OF MURMUR
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TIMING AND LOCATION OF MURMURS
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• CONFIGURATIONAL CHANGES IN THE ARTERIAL PULSE
• NORMAL
• ANACROTIC PULSE WITH SLOW INITIAL UPSTROKE
  AORTIC STENOSIS
• PULSUS BISFERIENS AORTIC REGURGITATION
• PULSUS BISFERIENS HYPERTROPHIC CARDIOMYOPATHY
• DICROTIC PULSE ACCENTUATED DICROTIC WAVE SEEN
  IN PATIENTS WITH SEPSIS, HYPOVOLEMIC SHOCK AND
  SEVERE CONGESTIVE HEART FAILURE

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JUGULAR VENOUS WAVEFORMS
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THE ARTERIAL PULSE
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VARIATIONS IN S2
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