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Title: Assessment of Cardiovascular System


1
Assessment of Cardiovascular System
  • By B.Lokay, MD, PhD

2
Lecture Objectives
  • Anatomy and physiology of cardiovascular system.
  • Developmental considerations
  • Transcultural considerations
  • History taking and physical examination
  • Main disorders of cardiovascular system
  • Congenital heart defects.
  • Valvular defects.
  • Heart failure.

3
Structure of the Cardiovascular system
4
Anatomical Structure of the Heart
5
Common abbreviations used to refer to chambers
  • RA right atrium
  • RV right ventricle
  • LA left atrium
  • LV left ventricle
  • AV atrioventricular valve
  • Left AV left atrioventricular valve
  • Right AV - right atrioventricular valve
  • SL semilunar valve

NB No valves are present between major veins and
atria. Hyperpressure leads to signs of congestion.
6
Topographical Landmarks of the Heart
7
Topographical Landmarks of the Heart
  • Precordium the part of the ventral surface of
    the body overlying the heart and stomach and
    comprising the epigastrium and the lower median
    part of the thorax

8
Topographical Landmarks
  • Each area corresponds to one of the hearts 4
    valves.
  • Aortic area - 2nd ICS to right of sternum
    (closure of the aortic valve loudest here).
  • Pulmonic area - 2nd ICS to left of sternum
    (closure of the pulmonic valve loudest here).
  • Tricuspid - 5th ICS left of sternal border
    (closure of tricuspid valve).
  • Mitral - 5th ICS left of the sternum just medial
    to MCL (closure of mitral valve). When cardiac
    output is increased as in anemia, anxiety, HTN,
    fever, the impulse may have greater force -
    inspect for lift or heave.

9
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10
Normal Heart Sounds
  • The first heart sound - systolic S1
  • Signals the closure of AV valves and the
    beginning of systole.
  • Consists of mitral M1 and tricuspid T1
    components.
  • Is loudest at the apex

11
  • The second heart sound - diastolic S2
  • Signals the closure of semilunar valves and the
    end of systole.
  • Consists of aortic A2 and pulmonic P2 components.
  • Is loudest at the base.
  • S1 S2 correspond respectively to the familiar
    "lub dub" often used to describe the sounds.

12
Effect of respiration
  • MoRe to the Right heart
  • Less to the Left
  • A split S2 when the aortic valve closes
    significantly earlier than the pulmonic valve,
    you can hear the two components separately.

13
Other Heart Sounds
  • Extra Heart Sounds
  • S3
  • is the result of vibrations produced during
    ventricular filling.
  • is normally heard only in some children and young
    adults, but it is considered abnormal in older
    individuals.
  • S4
  • is caused by the recoil of vibrations between the
    atria and ventricles following atrial
    contraction, at the end of diastole.
  • is rarely heard as a normal heart sound usually
    it is considered indicative of further cardiac
    evaluation.

14
Other Heart Sounds
  • Murmurs
  • are produced by vibrations within the heart
    chambers or in the major arteries from the back
    and forth flow of blood.
  • are classified as
  • 1. Innocent, occurring in individuals with no
    anatomic or physiologic abnormality.
  • 2. Functional, occurring in individuals with no
    anatomic cardiac defect but with a physiologic
    abnormality such as anemia.
  • 3. Organic, occurring in individuals with a
    cardiac defect with or without a physiologic
    abnormality.

15
The conduction system of the heart consists of
four structures
  • 1. The sinoatrial (SA) node, located within the
    rig atrial wall near the opening of the superior
    vena cava
  • 2. The atrioventricular (AV) node, also located
    within the right atrium but near the lower end of
    the septum
  • 3. The atrioventricular bundle (bundle of His),
    which extends from the atrioventricular node
    along each side of the interventricular septum
  • 4. Purkinje fibers, which extend from the
    atrioventricular bundle into the walls of the
    ventricles. The electric impulses from this
    conduction system can be recorded on an
    electrocardiogram.

16
Conduction System
17
Electrocardiography (ECG)
  • records the electrical impulses generated from
    the heart muscle and provides a graphic
    illustration of the summation of these impulses
    and their sequence and magnitude.

18
The ECG waves
  • P wave represents the electric activity
    associated with the sinoatrial node and the
    spread of the impulse over the atria. It is a
    wave of depolarization.
  • QRS complex (wave) is composed of three separate
    waves the Q wave, the R wave, and the S wave.
    They are all caused by currents generated when
    the ventricles depolarize before their
    contraction. Because ventricular depolarization
    requires septal and right and left ventricular
    depolarization, the electrical wave depicting
    these events is more complex than the smooth P
    wave.
  • P-R interval is measured from the beginning of
    the P wave to the beginning of the QRS complex.
    It is termed P-R instead of PQ because frequently
    the Q wave is absent. This interval represents
    the time that elapses from the begin Q-T
    intervalning of atrial depolarization to the
    beginning of ventricular depolarization.

19
The ECG waves
  • The T wave represents repolarization of the
    ventricles. The Q-T interval begins with the QRS
    complex and ends with the completion of the T
    wave. It represents ventricular j depolarization
    and repolarization. This interval varies with j
    the heart rate. The faster the rate, the shorter
    the Q-T interval. Therefore in children this
    interval is normally shorter than in adults.
  • The S-T segment is normally an isoelectric (flat)
    line that I connects the end of the S wave to the
    beginning of the T wave.
  • The T-P interval represents atrial and
    ventricular polarization in anticipation of the
    next cardiac cycle.

20
Pumping Ability
  • 4 to 6 L of blood per min throughout the body
  • Preload venous return
  • Afterload the opposing pressure the ventricles
    must generate to open aortic valve.

21
Developmental Considerations
  • Infants
  • Transition from fetal circulation to postnatal
    circulation. By 9 months anatomical closure of
    foramen ovale occurs.
  • S1 and S2 sounds similarly on auscultation. Pulse
    rate 120/min.
  • Horizontal position of the heart (till
    7-years-old).

22
Developmental Considerations
  • Infants
  • Apex impulse is located at the 4th intercostal
    space 1 to 2 cm outward from left midclavicular
    line.

23
Developmental Considerations
  • The pregnant female
  • By the end of pregnancy blood volume increases by
    30 to 40 .
  • Stroke volume and cardiac output are increased.
  • BP decreases due to vasodilation.
  • Pulse rate increases of 10 to 15 beats/min.

24
Developmental Considerations
25
Developmental Considerations
  • An aging adult
  • The incidence of CV diseases increases with age
    coronary artery disease, HBP, heart failure.

26
Transcultural considerations
  • Smoking widely spread in some societies.
  • HBP Afro-Americans, Mexican-Americans and Native
    Americans have higher risk of hypertension.
  • Serum cholesterol during childhood (4-19 yrs)
    Afro-American children have higher total
    cholesterol than Euro- and Mexican-Am. Children.
    This difference reverse during adulthood.
  • Obesity more than 50 of Am. population are
    overweight.
  • Diabetes the prevalence of diabetes increases in
    all groups in USA.

27
Physical Examination
  • Objectives
  • Subjective data.
  • Health history data.
  • Preparation.
  • Inspection general appearance, precordium.
  • Palpation peripheral pulses, apical impulse.
  • Percussion.
  • Auscultation heart sounds, murmurs.
  • Summary checklist.

28
Subjective data
29
Chest pain
Angina an important cardiac symptom. Clenched
fist sign is characteristic of angina.
  • Onset, location, character, aggravating and/or
    relieving factors
  • Character crashing, stabbing, burning,
    vise-like.
  • Associated symptoms sweating, ashen gray or pale
    skin, shortness of breath, nausea or vomiting,
    racing of heart, heart skips beat.

30
Subjective data
Paroxysmal nocturnal dyspnea (PND) occurs with
heart failure. Classically, the person awakens
after 2 hrs. of sleep, arises, and flings open
the window with the perception of needing fresh
air.
  • Dyspnea
  • Cause, onset, duration, affection by position,
  • Does shortness of breath interfere with
    activities of daily living?
  • Orthopnea
  • Is the need to assume a more upright position to
    breathe.
  • Note the exact number of pillows used.

31
Subjective data
Hemoptysis is often a pulmonary problem, but
also occurs with mitral stenosis
  • Cough duration, frequency, type, coughing up
    sputum (color, odor, blood tinged, aggravating
    and/or relieving factors.
  • Fatigue onset, relation to time of day?
  • Cyanosis or pallor occurs with myocardial
    infarction or low cardiac output.

32
Subjective data
  • Edema
  • Swelling of legs or dependent body part due to
    increased interstitial fluid.
  • Onset, recent change, relation to time of day,
    relieving factors, associated symptoms.
  • Nocturia
  • Occurs with heart failure in the person who is
    ambulatory during the day.

33
History taking.
  • Past cardiac history
  • ! Last ECG, stress ECG, serum chilesterol
    measurements, other heart tests?
  • Family cardiac history
  • Family history of hypertension, diabetes, heart
    problems, coronary artery disease (CAD), sudden
    death at younger age?
  • Personal habits (cardiac risk factors)
    nutrition, smoking, alcohol, exercise, drugs.

34
Additional history
  • For infants mothers health during pregnancy,
    feeding habits, growth, activity.
  • For children growth, activity, any joint pains
    or unexplained fever, frequent headaches or
    nosebleedings, streptococcal infection
    (tonsillitis).
  • For pregnant female any high PB during this or
    previous pregnancies, associated signs (weight
    gain, proteinuria), dizziness.
  • For aging adult any symptoms of heart diseases
    (HTN, CAD) or COPD, any recent changes,
    medications (digitalis), side effects
    environment.

35
Preparation
  • Bring to lab
  • Watch with second hand,
  • Stethoscope,
  • Marking pen and small centimeter ruler,
  • Alcohol swab (to clean endpiece).
  • Wear
  • loose T-shirt or some other garment that allows
    for practice of physical assessment

36
Inspection
  • Skin colour (cyanosis, pallor) and condition
  • Any obvious bulging on anterior thorax at the
    left
  • Edema
  • Orhtopnea

37
Palpation
  • Palpate the apical impulse (the point of maximal
    impulse, or PMI)
  • Location one intercostal space (usually 5th ICS)
    at left MCL,
  • Size normally 1 cm ? 2 cm,
  • Amplitude normally a shot, gentle tap,
  • Duration short, normally occupies only first
    half of systole.
  • Ask the client to exhale then hold it or turn
    him to the left side.

38
Palpation
39
Palpation
  • Palpate across the precordium for
  • Other pulsations,
  • Thrill palpable vibration due to strong heart
    murmur (like a purring cat),
  • Pericardial friction rubs are scratchy,
    high-pitched grating sounds, similar to pleural
    friction rubs, except that they are not affected
    by changes in respiration.
  • Accentuated S1 and S2.
  • A diffuse impulse (lift, heave).

40
Palpation
41
Percussion
  • Is used to estimate approximately heart borders
    and configuration.
  • Recently is displaced by the chest x-ray or
    EchoCG.
  • Helps to detect heart enlargement

Heart (cardiac) enlargement is due to increased
ventricular volume or thickening of heart
wall. Occurs with HTN, CAD, heart failure,
cardiomyopathy
42
Auscultation
43
Auscultation
  • A Z-pattern is recommended.
  • Before beginning alert the person for long
    duration of procedure.
  • Begin with diaphragm endpiece and use the
    following routing
  • Note the rate
  • the rhythm
  • Identify S1 and S2
  • Listen for extra heart sounds
  • Listen for murmurs

44
Auscultation (cont.)
  • Rhythm
  • Regular
  • Irregular
  • Synus arrythmia common variation. Rate ? on
    inspiration and ? on expiration.
  • Regularly irregular
  • Irregularly irregular no pattern to the sounds,
    beats come rapidly and at random intervals.
  • Pulse deficit occurs with atrial fibrillation,
    heart failure, detects weak heart contractions.

45
Auscultation (cont.)
  • Identify S1 and S2
  • Location and amplitude,
  • Correlation with peripheral pulses, PMI
  • Correlation with ECG waves
  • Lub or dup
  • Give description of origin.
  • Listen to sounds separately accentuation, split
    (fixed, paradoxical).

46
Auscultation (cont.)
  • Extra heart sounds
  • Midsystolic click
  • S3 normal, pathological (ventricular gallop)
  • S4 atrial gallop
  • Listen for murmurs
  • Characteristics timing, loudness, pitch,
    pattern, quality, location, radiation, posture

47
Grading murmurs
  • Grade I-VI
  • Refers to the severity of a heart murmur
    (blowing, whooshing, or rasping sound), which is
    the result of vibrations caused by turbulent
    blood flow patterns.
  • Murmurs are classified ("graded") depending on
    their ability to be heard by the examiner. The
    grading is on a scale with grade I being barely
    detectable.
  • An example of a murmur description is a "grade
    II/VI murmur." (This means the murmur is grade 2
    on a scale of 1 to 6).

48
Murmurs are classified according to their timing
within the cardiac cycle.
  • Systolic Between S1and S2.
  • Diastolic Between S2 and S1).
  • Systolic ejection Begin after the first heart
    sound, attain a peak during midsystole, and
    terminate before the second heart sound.
  • Pansystolic or holosystolic During all of
    systole.
  • Pandiastolic or holodiastolic During all of
    diastole.
  • Prodiastolic Early diastolic.
  • Presystolic Late diastolic.
  • Continuous Continue through all of systole and
    all or part of diastole.

49
Timing of murmurs
50
Conclusion
  • Function can be assessed to a large degree by
    findings in the history shortness of breath
    (SOB), edema of ankles/legs, pain, pulse rate and
    rhythm vital signs, signs and symptoms of oxygen
    deficit.
  • Location Heart lies behind and to the left of
    the sternum. The upper portion or atria (BASE)
    lies to the back the ventricles (APEX) points
    forward, the apex of the left ventricle actually
    touches the anterior chest wall near the left
    midclavicular line at or near the 5th left ICS.
    Known as point of maximal impulse (PMI) and is
    where apical beat is assessed. Impulse is a good
    index of heart size.
  • Landmarks for assessment The precordium is the
    area on the anterior chest overlying the heart.
    Hearts sounds are heard throughout the
    precordium, but there are 4 major areas for
    examining heart sounds.

51
Techniques of Assessment
  • Inspection- look for lift at apex.
  • Auscultation- Client should be assessed in supine
    position with head up to 45 deg. examiner stands
    at right side. Use diaphragm for basic sounds
    bell for murmurs and extra sounds.
  • Identify the heart rate, rhythm bell for murmurs
    aortic, pulmonic, mitral.

52
Heart Sounds
  • There are 2 basic normal heart sounds and several
    abnormal ones. Normal
  • S1 (produced by closure of the atrioventricular
    valves, mitral and tricuspid)- at mitral area and
    tricuspid area S1 is louder than S2. The sound is
    a dull, low pitched lub.
  • S2 (produced by closure of aortic and pulmonic
    valve) is higher pitched, shorter and is the
    dub sound. Heard best at the base (aortic and
    pulmonic areas) where S2 is louder than S1
  • Systole begins with the 1st sound. As ventricles
    start to contract, pressure within exceeds the
    atria, shutting the mitral and tricuspid valves.
    Blood is forced into the great vessels.
  • When the ventricles have emptied themselves, the
    pressure in the aorta and pulmonary arteries
    force the semilunar valves shut
    (aortic/pulmonic), which is the 2nd sound and
    diastole (ventricular relaxation) begins.

53
Other heart sounds
  • S3 rapid filling of the ventricle with blood
    heard following S2. Can be normal in young adults
    and children pathologic in elderly.
  • S4 atrial contraction and thought to result
    from stiffened left ventricle directly precedes
    S1. Heard in elderly.
  • Extra sounds snaps and clicks are associated
    with valves aortic and mitral stenosis,
    prosthetic valves.
  • Murmurs S1 or S2 is a swishing or blowing sounds
    caused by
  • Forward flow through a stenotic (narrowed) valve
  • Increased flow through a normal valve
  • Backward flow through a valve that fails to close
    (insufficiency).

54
  • Murmurs should be identified as systolic (S1) or
    diastolic (S2). Murmurs are common in children
    and occur often in the elderly.
  • Try to identify grade of murmur Grade I (barely
    audible) to Grade VI (loud and may be heard with
    the stethoscope not quite on the chest or barely
    touching the chest).
  • Documentation Normally, you should be able to
    note that S1, S2 heard without extra sounds.

55
Thanks for attention! Questions?
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