Assessment of Cardiovascular System

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Assessment of Cardiovascular System

• By B.Lokay, MD, PhD

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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.

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Structure of the Cardiovascular system
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Anatomical Structure of the Heart
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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.
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Topographical Landmarks of the Heart
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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

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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.

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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

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• 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.

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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.

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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.

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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.

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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.

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Conduction System
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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.

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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.

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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.

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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.

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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).

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Developmental Considerations

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

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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.

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Developmental Considerations
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Developmental Considerations

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

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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.

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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.

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Subjective data
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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.

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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.

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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.

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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.

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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.

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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.

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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

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Inspection

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

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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.

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Palpation
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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).

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Palpation
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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
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Auscultation
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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

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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.

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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).

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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

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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).

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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.

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Timing of murmurs
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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.

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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.

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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.

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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).

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• 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.

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Thanks for attention! Questions?