Card II

1. Assessment of the
Cardiovascular system
By; Habtamu Ayalew (Msc in CVN)

2. Learning Objective
At the end of this lesson you will expected to;
• Take history of CVS
• Do physical examination using the 4 methods of assessment (IPPA)
• Identify abnormal heart sounds S3,S4 and Murmurs
• Discuss the various diagnostic studies

3. Introduction
Cardiovascular diseases comprise the most prevalent serious disorders in industrialized
nations and are a rapidly growing problem in developing nations
Age-adjusted death rates for coronary heart disease have declined by two-thirds in the
last 4 decades in the United States, reflecting the identification and reduction of risk
factors as well as improved treatments and interventions for the management of
Coronary Artery Disease, Arrhythmias, and Heart failure

4. Conti..
Cardiovascular diseases remain the most common causes of death, responsible
for 35% of all deaths, almost 1 million deaths each year
Cardiovascular diseases are highly prevalent diagnosed in 80 million adults or
~35% of the adult population
The growing prevalence of obesity , type 2 diabetes mellitus , and metabolic
syndrome , which are important risk factors for atherosclerosis, now threatens to
reverse the progress that has been made in the age-adjusted reduction in the
mortality rate of coronary heart disease

5. Position and surface- land mark of the heart
• Chambers
• Atria—right and left
• Ventricles—right and left
• Valves
• Atrioventricular
• Tricuspid
• Mitral
• Semilunar
• Pulmonic
• Aortic

6. Conti..
• Structure and Function
(cont.)
• Neck vessels
• Carotid artery
• Jugular veins
• Internal
• External
• Venous pulse and pressure

7. Conti..
The pericardium:
• A double-walled fibro serous membrane that encloses the heart and
the roots of its great vessels
• The heart extends from the 2nd to the 5th intercostal space and from the
right border of the sternum to the left mid- clavicular line.

8. CARDIAC CYCLE
• The rhythmic movement of blood through the heart is the cardiac
cycle.
• It has two phases.
Diastole And
Systole.

9. Cont..
• In diastole, the ventricles relax and fill with blood.
• The heart’s contraction is systole, during systole blood is pumped
from the ventricles and fill the pulmonary and systemic arteries.
• During systole there is closure of the AV valves contributing the first
heart sound(S1) that signal the beginning of systole.

10. Heart sounds
• After the ventricles contents are ejected its pressure falls causing the
aortic and semilunar valve shut.
• This closure of the semilunar valves causes the second heart sound
(S2) and signals the end of systole

11. Cont..
• Events in the cardiac cycle generate normal heart sounds and
occasionally, extra heart sounds and murmurs that can be heard
through a stethoscope

12. Cont..

13. Heart Sounds – S1…(Lub)…
• S1: Closure of AV valves (mitral
and tricuspid valves: M1 before
T1)
• Correlates with the carotid pulse
• Loudest at the cardiac apex
• Can be split but not often

14. Cont..
S3…
• Due to volume overload
• Due to Rapid ventricular filling:
ventricular gallop
• S1 -- S2-S3 “lub-dub-dah,”
S4…
• Due to pressure overload
• Due to slow ventricular
contraction: atrial gallop
• S4-S1 — S2 “ta-lub-dub

15. Cont..
S3…
• low-pitched sound
• usually heard at the apex of the heart.
• caused by rapid filling and stretching
of the left ventricle when the left
ventricle is somewhat noncompliant.
• characteristic of volume overloading,
such as in CHF (especially left-sided
heart failure), tricuspid or mitral valve
insufficiency.
• S4
• a dull, low-pitched postsystolic atrial
gallop
• usually caused by reduced ventricular
compliance.
• best heard at the apex in the left lateral
position.
• occurs with reduced ventricular
compliance and is present in
conditions such as aortic stenosis,
hypertension, hypertrophic
cardiomyopathies, and coronary artery
disease.
• less specific for CHF than S3.

16. Cardiac Symptoms
The symptoms caused by heart disease result most commonly from
Myocardial ischemia due to coronary artery disease
Myocardial or pericardial inflammation/infection
Disturbance of the contraction and Relaxation of the myocardium
Obstruction to blood flow
Abnormal cardiac rhythm or rate

17. Cont..

18. Common symptoms
Chest pain
• Anginal pain usually has a substernal location with radiation And
aggravating factors
• The pain is deep, visceral, and intense
• Many patients describe it as a pressure-like sensation
• The duration of the pain is minutes, not seconds

19. Cont..

20. Dyspnea
• unexpected awareness of breathing
• It is due to
A sensation of increased force required of the respiratory muscles to
produce a volume change in the lungs
A reduction in compliance of the lungs
 Increased resistance to air flow
• Cardiac dyspnea is typically chronic

21. Orthopnea
• Dyspnoea that develops when a patient is supine because in an
upright position the patient's interstitial edema is redistributed
• Patients with severe orthopnea spend the night sitting up in a chair or
propped up on numerous pillows in bed

22. Cont..

23. Conti..
• Paroxysmal nocturnal dyspnea
• Severe dyspnea that wakes the patient from sleep so that he or she is
forced to get up gasping for breath
• It is because of a sudden failure of left ventricular output with an acute rise
in pulmonary venous and capillary pressures; this leads to transudation of
fluid into the interstitial tissues which increases the work of breathing
• The sequence may be precipitated by resorption of peripheral edema at
night while supine

24. Intermittent claudication
• Patients with claudication notice pain in one or both calves, thighs or
buttocks when they walk more than a certain distance
• Suggests peripheral vascular disease

25. Fatigue
• Fatigue is a common symptom of cardiac failure
• It may be associated with a reduced cardiac output and poor blood
supply to the skeletal muscles
• Other causes of fatigue, including lack of sleep, anemia and
depression

26. Others
• Paltypnea-orthodoxia
• Bendopnea
• Trepopnea
• Orthostatic dyspnea

27. Cont..

28. Cont..
Murmur
• Blood circulation through normal cardiac chambers and
valves usually makes no noise.
• However, some conditions create turbulent blood flow
that result in a murmur.
• A murmur is a blowing, swooshing sound, which can be
heard on the chest wall.

29. Conti…
• Conditions resulting in murmur includes:
• Velocity- of blood increases as in exercise, thyrotoxicosis
• Viscosity of blood decrease as in anemia
• Structural defects in the valve

30. Conti..
• Described by their location, timing, frequency, and intensity.
• Systolic murmurs: heard between the first and second heart
sounds..
• Diastolic murmurs: heard after S2 but before S1.
• Continuous murmurs: heard throughout the entire cardiac cycle
• Ejection click: a sharp clicking sound arising from the cardiac valves
• due to sudden swelling of the pulmonary artery, abrupt dilation of aorta or
forceful opening of aortic cusps
• Pericardial rub occurs due to sliding of 2 inflamed layers of
pericardium, best heard along left sternal edge in 3rd & 4th ICS

31. Conti..

32. Murmur grading
There is a standard way to grade murmur that is universally accepted
• Sytolic Murmur grading
• Grade I Very soft(heared in quite
room).
• Grade II Soft easily audible
• Grade III Moderate no thrill
• Grade IV very loud with thrill, heared
with stethoscope barley placed on
chest.
• Grade V loud and audible with
stethoscope just off the chest.
• Diastolic Murmur grading
• Grade I Very soft
• Grade II Soft
• Grade III Loud
• Grade III Loud with thrill

33. Conti..
• Purpose of cardiovascular examination are:
• To assess the patient appearance
• To assess effectiveness of the heart as a pump
• To assess filling volume and pressure
• To assess the cardiac out put
• To identify the presence of compensatory mechanism that
help to maintain cardiac out put

34. Subjective Data- Health History Questions
• Chest pain
• Dyspnea
• Orthopnea
• Cough
• Fatigue
• Cyanosis or pallor

35. Conti..
• Edema
• Nocturia
• Cardiac history
• Family cardiac history
• Personal habits (cardiac risk factors)

36. Objective Data—The Physical Exam
• Preparation
• Position and draping
• Room preparation
• Order of examination
• Equipment needed
• Marking pen
• Small centimeter ruler
• Stethoscope with diaphragm and bell end pieces
• Alcohol swab

37. INSPECTION
• Physical abnormalities such as
• dysmorphic facial features, chest & spine deformities e.g. shifting of
apical impulse in scoliosis
• Signs of respiratory distress
• Edema: periorbital/pedal/sacral,
• Diaphoresis
• Precordium: visible pulsations, chest shape, scars, dilated veins
• Skin: rheumatic nodules, pallor, cyanosis, or jaundice

38. Conti..
• The fingers should be evaluated for the presence of clubbing.
• It subsequent loss of the normal angle between the nail and the nail bed from
chronic cyanosis. E.g. IE, cyanotic heart

40. Central Vs Peripheral cyanosis
Mechanism Central Peripheral
Mechanism Diminished atrial oxygen Saturation Diminished flow of blood to the
local part
Site On skin and mucosal membrane
Eg. Lip cheeks, tongue
On the skin only
Climbing and polycythemia Usually Associated Not associated
Temperature of limb Warm Cold
Local Heat Cyanosis remain Cyanosis abolished
Pure oxygen Cyanosis decreased Cyanosis persist

41. Palpation
• Apical beat: located (4th in infants)5th left ICS in the midclavicular line
• Peripheral pulses: Compare the rate, rhythm, and quality of arterial
pulses bilaterally;
• The quality of the pulse is graded on a scale of 0 to 3 (absent, decreased,
normal, & bounding).
E.g. femoral pulses is bounding in PDA & absent in COA.
• Parasternal heave: a precordial impulse that may be felt; a palpable
thrust, which lifts the palpating hand
• seen in RVH & left atrial enlargement
• Thrills: palpable vibrations of murmur which accompany any murmur
of grade 3 or more

42. The arterial pulse
1. Rate of pulse
2. Rhythm
3. Presence or absence of
delay of the femoral pulse
compared with the radial
pulse (radio femoral
delay)
4. The character and volume
of the pulse

43. Conti..

44. Conti..
• Capillary Refill(<3 second)
• Skin: temperature, moisture, turgor
• Edema & hepatomegally : palpate the area for pitting; normal liver
margin 1-2 cm below the costal margin in the Rt MCL.

45. The blood pressure

46. Cortication of aorta
• Coarctation of the aorta is typically a discrete narrowing of the
thoracic aorta just distal to the left subclavian artery near the
insertion of the ligamentum arteriosum.
• However, the constriction may be proximal to the left subclavian
artery or rarely in the abdominal aorta.
It has the following future;
• Weak/absent of the femoral pulse.
• BP of the upper extremity greater than BP of the lower extremities.
• BP of the R+ > BP of the L+

47. Conti..

48. The face
Xanthelasma
Jaundice

49. Palpate Carotid Arteries
• Palpate each carotid arteries medial to the sternomastiod muscle in
the lower third of the neck.
• Excessive vagal stimulation here could slow down the heart rate
and palpate gently.
• Palpate only one carotid at a time to avoid compromising arterial
blood to the brain.
•

51. Cont..
• Palpate only one carotid at a time to avoid compromising arterial
blood to the brain.
• Feel the contour and amplitude of the pulse.
• Your finding should be the same bilaterally.
• Diminished pulse fells small and weak occurs with decreased
stroke volume

52. Auscultate the carotid artery
• For persons older than middle age or who show symptoms or signs of
cardiovascular disease, auscultate each carotid artery for the presence
of bruits.
• This is blowing, swishing sound indicating blood flow turbulence;
normally there is none.
• Ask the person to hold his or her breath while you listen so that
tracheal sounds do not mask or mimic a carotid artery bruit.

53. The jugular vein
• From the jugular vein you can asses the central venous pressure(CVP)
and thus the heart efficiency as pump.
• Although the external jugular vein is easier to see, the internal (esp.
the right) is attached more directly to the superior venacava and thus
is more reliable for assessment.
• You can not see the internal jugular vein it self but you can see its
pulsation.

54. Steps for Measuring JVP
• Position the person any where from a 30-45 degree angle, where ever
you can best see the pulsations.
• Turn the person’s head slightly away from the examined side.
• Note the external jugular vein overlying the sternomastoid muscle.

55. Cont..
• In some persons, the veins are not visible at all; where as in others,
they are full in the supine position.
• As the person is raised to a sitting position, these external jugulars
flatten and disappear, usually at 45 degree.
• Full distention of external jugular veins above 45 degree signify
increased CVP.

56. Cont..
• Now look for pulsation’s of the internal jugular vein in the area of the
supra sternal notch or around the origin of the sternomastoid muscle
around the clavicle.
• You must be able to distinguish internal jugular vein pulsation from
that of the carotid artery.
• It is easy to confuse because they lie close together

57. Cont..

58. Summary of Measuring JVP

59. JVD

60. Cont..

61. Cont..

62. lower limbs
• Check for pitting edema
compressing for 15sec at medial
malleolus and distal shaft of tibia
• Look for evidence of Achilles
tendon xanthoma due to
hyperlipidaemia

63. Causes of edema

64. Peripheral arterial pulsation
• A bruit may be heard if the artery is narrowed

65. Vascular disease related skin manifestations
• venous ulcer has an irregular margin,
pale surrounding neo-epithelium , and
a pink base of granulation tissue
• There is often a history of deep
venous thrombosis
• The skin is warm and edema is often
present

66. Conti..
• This arterial ulcer has a regular
margin and 'punched out'
appearance
• The surrounding skin is cold
• The peripheral pulses are absent

67. Conti..
• Diabetic neuropathic ulcer
• Neuropathic ulcers are painless
and are associated with reduced
sensation in the surrounding
skin

68. Percussion:
• Has been used to out line the heart’s borders, replaced by the chest x-
ray study which is more accurate in detecting heart enlargement
• To search for cardiac enlargement in out patient or at home, place your
stationary finger in the person’s fifth intercostals space on the left side
of the chest near the anterior axillary line.

69. Cont..
• Slide your stationary hand to ward your self percussing as you go, and
note the change of sound from resonance over the lung to dull over
the heart)
• Normally, the left border of cardiac dullness is at the mid clavicular
line in the 5th interspaces and slopes in to ward the sternum as you
progress upward that by the second interspaces the border of dullness
concede with the left sternal border.
• The right border of dullness normally matches the sternal border.

70. Auscultate the heart sounds
• Identify auscultatory areas
• Note the rate and rhythm
• Sinus arrhythmia
• Pulse deficit
• Identify S1 and S2
• S1 is louder than S2 at the apex
• S1 coincides with carotid artery pulse
• S1 coincides with R wave on electrocardiogram
• Listen to S1 and S2 separately
• Listen for extra heart sounds
• Listen for murmurs

71. Auscultation:
Auscultatory Sites

72. Auscultation
• With a stethoscope
• Use diaphragm to assess higher pitched sounds
• Needs a lot of practice and experience
• Listen in a quiet area or to close eyes to reduce conflicting stimuli

73. Auscultatory Sites
• The auscultatory Sites are close to but not the same as the anatomic
locations of the valves.
• Aortic area2nd ICS at the right sternal border
• Pulmonic  2nd ICS at the left sternal border
• Tricuspid  lt lower sternal border
• Mitral cardiac apex

74. Summery:
1. Neck
 Carotid pulse- observe and palpate
 Observe jugular venous pulse
 Estimate jugular venous pressure

75. Cont..
. Pericardium
Inspect and palpate
• Describe location of apical pulse
• Note any heave(lift) or thrill
Auscultation
• Identify anatomic areas where you listen
• Note rate and rhythm of the heart beat
• Identify s1 and s2 and note any variation
• Listen in the systole and diastole for any extra heart sounds

76. Cont..
oListen in systole and diastole for any murmur
oRepeat the sequence with bell
oListen at the apex with person in left lateral position
oListen at the base with person in sitting position

77. Arteries
• Each heart beat creates a pressure wave (pulse) which makes the
arteries expand and recoil.
• All arteries have pulse all over the body, but you can feel it only at
body site where the artery lies close to the skin and over a bone

79. Thank you on the bright side !!!