Heart and Neck Vessels

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Heart and Neck VesselsHeart and Neck Vessels

Chapter 19Chapter 19


Chapter 19: Heart and Neck VesselsChapter 19: Heart and Neck Vessels

Cardiovascular SystemCardiovascular System

Cardiovascular system consists of heart (a Cardiovascular system consists of heart (a muscular pump) and blood vesselsmuscular pump) and blood vessels

Blood vessels are arranged in two continuous Blood vessels are arranged in two continuous loopsloops Pulmonary circulationPulmonary circulation Systemic circulationSystemic circulation

When the heart contracts, it pumps blood When the heart contracts, it pumps blood simultaneously into both loopssimultaneously into both loops

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Structure and FunctionStructure and Function

Position and surface landmarksPosition and surface landmarks Precordium: area on anterior chest overlying heart Precordium: area on anterior chest overlying heart

and great vesselsand great vessels• Great vessels: major arteries and veins connected to Great vessels: major arteries and veins connected to

heartheart

• Heart and great vessels are located between lungs in Heart and great vessels are located between lungs in middle third of thoracic cage, called mediastinummiddle third of thoracic cage, called mediastinum

• Heart extends from second to fifth intercostal space and Heart extends from second to fifth intercostal space and from right border of sternum to left midclavicular linefrom right border of sternum to left midclavicular line

• The “top” of heart is broader base, and “bottom” is the The “top” of heart is broader base, and “bottom” is the apex, which points down and to leftapex, which points down and to left

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Structure and FunctionStructure and Function (cont.)(cont.)

Position and surface landmarks (cont.)Position and surface landmarks (cont.) During contraction, apex beats against chest wall, During contraction, apex beats against chest wall,

producing an apical impulseproducing an apical impulse• Palpable in most people, normally at fifth intercostal Palpable in most people, normally at fifth intercostal

space, 7 to 9 cm from midsternal linespace, 7 to 9 cm from midsternal line

• Heart rotated so that its right side is anterior and its left Heart rotated so that its right side is anterior and its left side is mostly posteriorside is mostly posterior

Heart has four chambersHeart has four chambers• Right ventricle forms greatest area of anterior cardiac Right ventricle forms greatest area of anterior cardiac

surfacesurface

• Left ventricle lies behind right ventricle and forms apex Left ventricle lies behind right ventricle and forms apex and slender area of left borderand slender area of left border

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Position and surface landmarks (cont.)Position and surface landmarks (cont.) Heart has four chambers (cont.)Heart has four chambers (cont.)

• Right atrium lies to right and above right ventricle and Right atrium lies to right and above right ventricle and forms right border forms right border

• Left atrium located posteriorly, with only a small portion, Left atrium located posteriorly, with only a small portion, the left atrial appendage, showing anteriorlythe left atrial appendage, showing anteriorly

Great vessels lie bunched above base of heartGreat vessels lie bunched above base of heart• Superior and inferior vena cava return unoxygenated Superior and inferior vena cava return unoxygenated

venous blood to right side of heartvenous blood to right side of heart

• Pulmonary artery leaves right ventricle, bifurcates, and Pulmonary artery leaves right ventricle, bifurcates, and carries venous blood to lungscarries venous blood to lungs

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Position and surface landmarks (cont.)Position and surface landmarks (cont.) Pulmonary veins return freshly oxygenated blood Pulmonary veins return freshly oxygenated blood

to left side of heart, and aorta carries it out to bodyto left side of heart, and aorta carries it out to body• Aorta ascends from left ventricle, arches back at level of Aorta ascends from left ventricle, arches back at level of

sternal angle, and descends behind heartsternal angle, and descends behind heart

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Precordium, Apex, and BasePrecordium, Apex, and Base

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Heart wall, chambers, and valvesHeart wall, chambers, and valves Heart wall has numerous layersHeart wall has numerous layers

• Pericardium: tough, fibrous, double-walled sac that Pericardium: tough, fibrous, double-walled sac that surrounds and protects heartsurrounds and protects heart

Has two layers that contain a few milliliters of serous Has two layers that contain a few milliliters of serous pericardial fluid; this ensures smooth, friction-free pericardial fluid; this ensures smooth, friction-free movement of heart musclemovement of heart muscle

• Pericardium: adherent to great vessels, esophagus, Pericardium: adherent to great vessels, esophagus, sternum, and pleurae and anchored to diaphragmsternum, and pleurae and anchored to diaphragm

• Myocardium: muscular wall of heart; it does pumpingMyocardium: muscular wall of heart; it does pumping

• Endocardium: thin layer of endothelial tissue that lines Endocardium: thin layer of endothelial tissue that lines inner surface of heart chambers and valvesinner surface of heart chambers and valves

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Heart wall, chambers, and valves (cont.)Heart wall, chambers, and valves (cont.) Common metaphor is to think of heart as a pumpCommon metaphor is to think of heart as a pump

• But consider that heart is actually two pumps; right side But consider that heart is actually two pumps; right side of heart pumps blood into lungs, and left side of heart of heart pumps blood into lungs, and left side of heart simultaneously pumps blood into bodysimultaneously pumps blood into body

• Two pumps are separated by an impermeable wall, Two pumps are separated by an impermeable wall, septumseptum

Each side has an atrium and a ventricleEach side has an atrium and a ventricle• Atrium: thin-walled reservoir for holding bloodAtrium: thin-walled reservoir for holding blood

• Ventricle: thick-walled, muscular pumping chamberVentricle: thick-walled, muscular pumping chamber

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Heart wall, chambers, and valves (cont.)Heart wall, chambers, and valves (cont.) Four chambers separated by valves, whose main Four chambers separated by valves, whose main

purpose is to prevent backflow of bloodpurpose is to prevent backflow of blood• Valves are unidirectional: can only open one way Valves are unidirectional: can only open one way

• Valves open and close passively in response to pressure Valves open and close passively in response to pressure gradients in moving bloodgradients in moving blood

Four valves in heartFour valves in heart• Two atrioventricular (AV) valvesTwo atrioventricular (AV) valves

• Two semilunar (SL) valvesTwo semilunar (SL) valves

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Heart wall, chambers, and valves (cont.)Heart wall, chambers, and valves (cont.) Two AV valves separate atria and ventriclesTwo AV valves separate atria and ventricles

• Tricuspid valve: right AV valveTricuspid valve: right AV valve

• Bicuspid, or mitral valve: left AV valveBicuspid, or mitral valve: left AV valve Valves’ thin leaflets are anchored by collagenous fibers Valves’ thin leaflets are anchored by collagenous fibers

(chordae tendineae) to papillary muscles embedded in (chordae tendineae) to papillary muscles embedded in ventricle floorventricle floor

• AV valves open during heart’s filling phase, or diastole, AV valves open during heart’s filling phase, or diastole, to allow ventricles to fill with bloodto allow ventricles to fill with blood

• During pumping phase, or systole, AV valves close to During pumping phase, or systole, AV valves close to prevent regurgitation of blood back up into atriaprevent regurgitation of blood back up into atria

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Heart wall, chambers, and valves (cont.)Heart wall, chambers, and valves (cont.) SL valves are set between ventricles and arteriesSL valves are set between ventricles and arteries

• Each valve has three cusps that look like half moonsEach valve has three cusps that look like half moons

• Pulmonic valve: SL valve in right side of heartPulmonic valve: SL valve in right side of heart

• Aortic valve: SL valve in left side of heartAortic valve: SL valve in left side of heart Open during pumping, or systole, to allow blood to be Open during pumping, or systole, to allow blood to be

ejected from heartejected from heart

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Heart wall, chambers, and valves (cont.)Heart wall, chambers, and valves (cont.) SL valves are set between ventricles and arteries SL valves are set between ventricles and arteries

(cont.)(cont.)• No valves are present between vena cava and right No valves are present between vena cava and right

atrium, or between pulmonary veins and left atrium, for atrium, or between pulmonary veins and left atrium, for this reasonthis reason

Abnormally high pressure in left side of heart gives a Abnormally high pressure in left side of heart gives a person symptoms of pulmonary congestionperson symptoms of pulmonary congestion

Abnormally high pressure in right side of heart shows in Abnormally high pressure in right side of heart shows in neck veins and abdomenneck veins and abdomen

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Chambers and valvesChambers and valves

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Direction of blood flowDirection of blood flow Unoxygenated red blood drains into vena cava, Unoxygenated red blood drains into vena cava,

follows route of venous bloodfollows route of venous blood• From liver to right atrium (RA) through inferior vena cavaFrom liver to right atrium (RA) through inferior vena cava

Superior vena cava drains venous blood from the head and Superior vena cava drains venous blood from the head and upper extremitiesupper extremities

From RA, venous blood travels through tricuspid valve to From RA, venous blood travels through tricuspid valve to right ventricle (RV)right ventricle (RV)

• From RV, venous blood flows through pulmonic valve to From RV, venous blood flows through pulmonic valve to pulmonary arterypulmonary artery

Pulmonary artery delivers unoxygenated blood to lungsPulmonary artery delivers unoxygenated blood to lungs

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Direction of blood flow (cont.)Direction of blood flow (cont.) Unoxygenated red blood drains into vena cava, Unoxygenated red blood drains into vena cava,

follows route of venous blood (cont.)follows route of venous blood (cont.)• Lungs oxygenate bloodLungs oxygenate blood

Pulmonary veins return fresh blood to LAPulmonary veins return fresh blood to LA

• From LA, arterial blood travels through mitral valve to LVFrom LA, arterial blood travels through mitral valve to LV LV ejects blood through aortic valve into aortaLV ejects blood through aortic valve into aorta

• Aorta delivers oxygenated blood to bodyAorta delivers oxygenated blood to body

Circulation is continuous loop; blood is kept Circulation is continuous loop; blood is kept moving by continually shifting pressure gradientsmoving by continually shifting pressure gradients• Blood flows from area of higher pressure to area of lower Blood flows from area of higher pressure to area of lower

pressurepressure

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Cardiac cycleCardiac cycle Rhythmic flow of blood through heart is cardiac Rhythmic flow of blood through heart is cardiac

cyclecycle• Has two phases, diastole and systoleHas two phases, diastole and systole

• Diastole: ventricles relax and fill with blood; this takes up Diastole: ventricles relax and fill with blood; this takes up two thirds of cardiac cycletwo thirds of cardiac cycle

• Systole: heart’s contraction, blood pumped from Systole: heart’s contraction, blood pumped from ventricles fills pulmonary and systemic arteries; this is ventricles fills pulmonary and systemic arteries; this is one third of cardiac cycleone third of cardiac cycle

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Cardiac cycle (cont.)Cardiac cycle (cont.) DiastoleDiastole

• Ventricles relaxed, and AV valves, tricuspid and mitral, Ventricles relaxed, and AV valves, tricuspid and mitral, are open; opening of normal valve is silentare open; opening of normal valve is silent

• Pressure in atria higher than that in ventricles, so blood Pressure in atria higher than that in ventricles, so blood pours rapidly into ventriclespours rapidly into ventricles

This first passive filling phase called or protodiastolic fillingThis first passive filling phase called or protodiastolic filling

• Toward end of diastole, atria contract and push last Toward end of diastole, atria contract and push last amount of blood into ventriclesamount of blood into ventricles

This active filling phase called presystole, or atrial systoleThis active filling phase called presystole, or atrial systole

Note that atrial systole occurs during ventricular Note that atrial systole occurs during ventricular diastole, a confusing but important pointdiastole, a confusing but important point

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Cardiac cycle (cont.)Cardiac cycle (cont.) SystoleSystole

• Ventricular pressure becomes higher than that in atria, Ventricular pressure becomes higher than that in atria, so mitral and tricuspid valves closeso mitral and tricuspid valves close

• Closure of AV valves contributes to first heart sound (SClosure of AV valves contributes to first heart sound (S11) )

and signals beginning of systoleand signals beginning of systole AV valves close to prevent any regurgitation of blood back AV valves close to prevent any regurgitation of blood back

up into atria during contractionup into atria during contraction

• For a very brief moment, all four valves are closed and For a very brief moment, all four valves are closed and ventricular walls contractventricular walls contract

Isometric contraction: this contraction against closed Isometric contraction: this contraction against closed system works to build high level pressure in ventriclessystem works to build high level pressure in ventricles

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Cardiac cycle (cont.)Cardiac cycle (cont.) Systole (cont.)Systole (cont.)

• Consider left side of heartConsider left side of heart

• When pressure in ventricle finally exceeds pressure in When pressure in ventricle finally exceeds pressure in aorta, aortic valve opens and blood is ejected rapidlyaorta, aortic valve opens and blood is ejected rapidly

After ventricle’s contents are ejected, its pressure falls After ventricle’s contents are ejected, its pressure falls

• When pressure falls below pressure in aorta, some blood When pressure falls below pressure in aorta, some blood flows backward toward ventricle, causing aortic valve to flows backward toward ventricle, causing aortic valve to closeclose

• This closure of semilunar valves causes second heart This closure of semilunar valves causes second heart sound (Ssound (S22) and signals end of systole) and signals end of systole

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Cardiac cycle (cont.)Cardiac cycle (cont.) Diastole againDiastole again

• Now all four valves are closed and ventricles relax Now all four valves are closed and ventricles relax Isometric or isovolumic relaxationIsometric or isovolumic relaxation

• Atria have been filling with blood delivered from lungsAtria have been filling with blood delivered from lungs

• Atrial pressure now higher than relaxed ventricular Atrial pressure now higher than relaxed ventricular pressurepressure

• Mitral valve opens and diastolic filling begins againMitral valve opens and diastolic filling begins again

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Cardiac cycle (cont.)Cardiac cycle (cont.) Events in right and left sides of heartEvents in right and left sides of heart

• Same events happening in right side of heartSame events happening in right side of heart But pressures in right side of heart are much lower than But pressures in right side of heart are much lower than

those of left side because less energy needed to pump those of left side because less energy needed to pump blood to its destination, pulmonary circulationblood to its destination, pulmonary circulation

Events occur just slightly later in right side of heart Events occur just slightly later in right side of heart because of route of myocardial depolarizationbecause of route of myocardial depolarization

• Results in two components to each of the heart soundsResults in two components to each of the heart sounds In first heart sound, mitral component (MIn first heart sound, mitral component (M11) closes just ) closes just

before tricuspid component (Tbefore tricuspid component (T11))

And with SAnd with S22, aortic closure (A, aortic closure (A22) occurs slightly before ) occurs slightly before

pulmonic closure (Ppulmonic closure (P22))

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Heart soundsHeart sounds Events in cardiac cycle generate sounds that can Events in cardiac cycle generate sounds that can

be heard through a stethoscope over chest wall be heard through a stethoscope over chest wall These include normal heart sounds and, These include normal heart sounds and,

occasionally, extra heart sounds and murmursoccasionally, extra heart sounds and murmurs

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Heart sounds (cont.)Heart sounds (cont.) Normal heart sounds: first heart sound (SNormal heart sounds: first heart sound (S11) )

• Occurs with closure of AV valves and thus signals Occurs with closure of AV valves and thus signals beginning of systolebeginning of systole

• Mitral component of first sound (MMitral component of first sound (M11) slightly precedes ) slightly precedes

tricuspid component (Ttricuspid component (T11) ) Usually hear these two components fused as one sound Usually hear these two components fused as one sound Can hear SCan hear S11 over all precordium, but loudest at apex over all precordium, but loudest at apex

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Heart sounds (cont.)Heart sounds (cont.) Normal heart sounds: second heart sound (SNormal heart sounds: second heart sound (S22) )

• Occurs with closure of semilunar valves and signals end Occurs with closure of semilunar valves and signals end of systoleof systole

• Aortic component of second sound (AAortic component of second sound (A22) slightly precedes ) slightly precedes

pulmonic component (Ppulmonic component (P22)) Although heard over all precordium, S2 loudest at baseAlthough heard over all precordium, S2 loudest at base

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Heart sounds (cont.)Heart sounds (cont.) Effect of respirationEffect of respiration

• Volume of right and left ventricular systole is just about Volume of right and left ventricular systole is just about equal, but can be affected by respirationequal, but can be affected by respiration

To learn this, consider the phrase: MoRe to the Right To learn this, consider the phrase: MoRe to the Right heart, Less to the Leftheart, Less to the Left

• That means that during inspiration, intrathoracic pressure That means that during inspiration, intrathoracic pressure is decreasedis decreased

• This pushes more blood into vena cava, increasing This pushes more blood into vena cava, increasing venous return to right side of heart, which increases right venous return to right side of heart, which increases right ventricular stroke volumeventricular stroke volume

• Increased volume prolongs right ventricular systole and Increased volume prolongs right ventricular systole and delays pulmonic valve closuredelays pulmonic valve closure

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Heart soundsHeart sounds (cont.)(cont.) Effect of respiration (cont.)Effect of respiration (cont.)

• Meanwhile, on left side, greater amount of blood Meanwhile, on left side, greater amount of blood sequestered in lungs during inspirationsequestered in lungs during inspiration

• This momentarily decreases amount returned to left side This momentarily decreases amount returned to left side of heart, decreasing left ventricular stroke volumeof heart, decreasing left ventricular stroke volume

• Decreased volume shortens left ventricular systole and Decreased volume shortens left ventricular systole and allows aortic valve to close a bit earlierallows aortic valve to close a bit earlier

• When aortic valve closes significantly earlier than When aortic valve closes significantly earlier than pulmonic valve, you can hear two components pulmonic valve, you can hear two components separately; this is a split Sseparately; this is a split S22

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Heart sounds (cont.)Heart sounds (cont.) Extra heart sounds: third heart sound (SExtra heart sounds: third heart sound (S33))

• Normally diastole is silent eventNormally diastole is silent event

• However, in some conditions, ventricular filling creates However, in some conditions, ventricular filling creates vibrations that can be heard over chestvibrations that can be heard over chest

• SS33 occurs when ventricles resistant to filling during early occurs when ventricles resistant to filling during early

rapid filling phase (protodiastole)rapid filling phase (protodiastole)

• Occurs immediately after SOccurs immediately after S22, when AV valves open and , when AV valves open and

atrial blood first pours into ventriclesatrial blood first pours into ventricles

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Heart sounds (cont.)Heart sounds (cont.) Extra heart sounds: fourth heart sound (SExtra heart sounds: fourth heart sound (S44))

• Occurs at end of diastole, at presystole, when ventricle Occurs at end of diastole, at presystole, when ventricle resistant to fillingresistant to filling

• Atria contract and push blood into noncompliant ventricleAtria contract and push blood into noncompliant ventricle

• This creates vibrations that are heard as SThis creates vibrations that are heard as S44

• SS44 occurs just before S occurs just before S11

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Heart sounds (cont.)Heart sounds (cont.) Extra heart sounds: murmursExtra heart sounds: murmurs

• Blood circulating through normal cardiac chambers and Blood circulating through normal cardiac chambers and valves usually makes no noisevalves usually makes no noise

• However, some conditions create turbulent blood flow However, some conditions create turbulent blood flow and collision currentsand collision currents

• These result in a murmur, much like a pile of stones or a These result in a murmur, much like a pile of stones or a sharp turn in a stream creates a noisy water flowsharp turn in a stream creates a noisy water flow

• A murmur is a gentle, blowing, swooshing sound that can A murmur is a gentle, blowing, swooshing sound that can be heard on chest wallbe heard on chest wall

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Heart soundsHeart sounds (cont.)(cont.) Extra heart sounds: murmurs (cont.)Extra heart sounds: murmurs (cont.)

• Conditions resulting in murmurConditions resulting in murmur Velocity of blood increases (flow murmur), e.g., in exercise, Velocity of blood increases (flow murmur), e.g., in exercise,

thyrotoxicosisthyrotoxicosis Viscosity of blood decreases, e.g., in anemiaViscosity of blood decreases, e.g., in anemia Structural defects in valves, narrowed valve, incompetent Structural defects in valves, narrowed valve, incompetent

valvevalve Unusual openings occur in chambers, dilated chamber, Unusual openings occur in chambers, dilated chamber,

wall defectwall defect

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Heart sounds (cont.)Heart sounds (cont.) Characteristics of soundCharacteristics of sound

• All heart sounds are described by:All heart sounds are described by: Frequency or pitch: described as high pitched or low Frequency or pitch: described as high pitched or low

pitchedpitched– Although these terms are relative because all are low-Although these terms are relative because all are low-

frequency sounds, and need good stethoscope to hear themfrequency sounds, and need good stethoscope to hear them Intensity or loudness: loud or softIntensity or loudness: loud or soft Duration: very short for heart sounds; silent periods are Duration: very short for heart sounds; silent periods are

longerlonger Timing: systole or diastoleTiming: systole or diastole

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ConductionConduction Heart has unique ability: automaticityHeart has unique ability: automaticity

• Can contract by itself, independent of any signals or Can contract by itself, independent of any signals or stimulation from bodystimulation from body

• Contracts in response to an electrical current conveyed Contracts in response to an electrical current conveyed by a conduction systemby a conduction system

• Specialized cells in sinoatrial (SA) node, near superior Specialized cells in sinoatrial (SA) node, near superior vena cava initiate an electrical impulsevena cava initiate an electrical impulse

• Because SA node has intrinsic rhythm, it is called the Because SA node has intrinsic rhythm, it is called the pacemakerpacemaker

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Conduction (cont.)Conduction (cont.) Heart has unique ability: automaticity (cont.)Heart has unique ability: automaticity (cont.)

• Current flows in orderly sequence, first across atria to AV Current flows in orderly sequence, first across atria to AV node low in atrial septumnode low in atrial septum

• There, it is delayed slightly so that atria have time to There, it is delayed slightly so that atria have time to contract before ventricles are stimulatedcontract before ventricles are stimulated

• Then, impulse travels to bundle of His, right and left Then, impulse travels to bundle of His, right and left bundle branches, and then through ventriclesbundle branches, and then through ventricles

• Electrical impulse stimulates heart to do its work, which Electrical impulse stimulates heart to do its work, which is to contractis to contract

• Small amount of electricity spreads to body surface, and Small amount of electricity spreads to body surface, and can be measured and recorded on electrocardiograph can be measured and recorded on electrocardiograph (ECG)(ECG)

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Conduction (cont.)Conduction (cont.) Heart has unique ability: automaticity (cont.)Heart has unique ability: automaticity (cont.)

• ECG waves arbitrarily labeled PQRST, which stand forECG waves arbitrarily labeled PQRST, which stand for

• P wave: depolarization of atriaP wave: depolarization of atria

• P-R interval: from beginning of P wave to beginning of P-R interval: from beginning of P wave to beginning of QRS complex (time necessary for atrial depolarization plus QRS complex (time necessary for atrial depolarization plus

time for impulse to travel through AV node to ventricles)time for impulse to travel through AV node to ventricles)

• QRS complex: depolarization of ventriclesQRS complex: depolarization of ventricles

• T wave: repolarization of ventriclesT wave: repolarization of ventricles

• Electrical events slightly precede mechanical events in Electrical events slightly precede mechanical events in heartheart

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Pumping abilityPumping ability In resting adult, heart normally pumps between 4 In resting adult, heart normally pumps between 4

and 6 L of blood per minute throughout bodyand 6 L of blood per minute throughout body• This cardiac output equals volume of blood in each This cardiac output equals volume of blood in each

systole (called stroke volume) times number of beats per systole (called stroke volume) times number of beats per minute (rate)minute (rate)

• Heart can alter its cardiac output to adapt to metabolic Heart can alter its cardiac output to adapt to metabolic needs of bodyneeds of body

• Preload and afterload affect heart’s ability to increase Preload and afterload affect heart’s ability to increase cardiac outputcardiac output

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Pumping ability (cont.)Pumping ability (cont.) Preload: venous return that builds during diastolePreload: venous return that builds during diastole

• Length to which ventricular muscle stretched at end of Length to which ventricular muscle stretched at end of diastole just before contractiondiastole just before contraction

• When volume of blood returned to ventricles increasedWhen volume of blood returned to ventricles increased Muscle bundles stretched beyond normal resting stateMuscle bundles stretched beyond normal resting state Force of this switch is preloadForce of this switch is preload

• According to Frank-Starling law, greater the stretch, the According to Frank-Starling law, greater the stretch, the stronger is heart’s contractionstronger is heart’s contraction

• This increased contractility results in an increased This increased contractility results in an increased volume of blood ejected, increased stroke volumevolume of blood ejected, increased stroke volume

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Pumping ability (cont.)Pumping ability (cont.) Afterload: opposing pressure ventricle must Afterload: opposing pressure ventricle must

generate to open aortic valve against higher aortic generate to open aortic valve against higher aortic pressurepressure• Resistance against which ventricle must pump its blood Resistance against which ventricle must pump its blood

• Once ventricle is filled with blood, ventricular end Once ventricle is filled with blood, ventricular end diastolic pressure is 5 to 10 mm Hg, whereas that in diastolic pressure is 5 to 10 mm Hg, whereas that in aorta is 70 to 80 mm Hg. aorta is 70 to 80 mm Hg.

To overcome this difference, ventricular muscle tenses, To overcome this difference, ventricular muscle tenses, isovolumic contractionisovolumic contraction

After aortic valve opens, rapid ejection occursAfter aortic valve opens, rapid ejection occurs

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Neck vesselsNeck vessels Cardiovascular assessment includes survey of Cardiovascular assessment includes survey of

vascular structures in neckvascular structures in neck• Carotid arteryCarotid artery

• Jugular veinsJugular veins

These vessels reflect efficiency of cardiac functionThese vessels reflect efficiency of cardiac function

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Neck vessels: carotid artery pulseNeck vessels: carotid artery pulse Carotid artery is a central arteryCarotid artery is a central artery

• Close to heart; timing closely coincides with ventricular Close to heart; timing closely coincides with ventricular systolesystole

• Located in groove between trachea and sternomastoid Located in groove between trachea and sternomastoid muscle, medial to and along-side that musclemuscle, medial to and along-side that muscle

• Note characteristics of its waveform Note characteristics of its waveform Smooth rapid upstrokeSmooth rapid upstroke Summit rounded and smoothSummit rounded and smooth Downstroke more gradual and has a dicrotic notch caused Downstroke more gradual and has a dicrotic notch caused

by closure of aortic valveby closure of aortic valve

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Neck vessels: jugular venous pulse and Neck vessels: jugular venous pulse and pressurepressure Jugular veins empty unoxygenated blood directly Jugular veins empty unoxygenated blood directly

into superior vena cavainto superior vena cava• Because no cardiac valve exists to separate superior Because no cardiac valve exists to separate superior

vena cava from right atrium, jugular veins give vena cava from right atrium, jugular veins give information about activity on right side of heartinformation about activity on right side of heart

• Specifically reflect filling pressure and volume changesSpecifically reflect filling pressure and volume changes

• Jugular veins expose this because volume and pressure Jugular veins expose this because volume and pressure increase when right side of heart fails to pump efficientlyincrease when right side of heart fails to pump efficiently

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Neck vessels: jugular venous pulse and Neck vessels: jugular venous pulse and pressure (cont.)pressure (cont.) Two jugular veins present in each side of neck Two jugular veins present in each side of neck

• Larger internal jugular lies deep and medial to Larger internal jugular lies deep and medial to sternomastoid musclesternomastoid muscle

• Usually not visible, although diffuse pulsations may be Usually not visible, although diffuse pulsations may be seen in sternal notch when person is supineseen in sternal notch when person is supine

• External jugular vein is more superficial; lies lateral to External jugular vein is more superficial; lies lateral to sternomastoid muscle, above claviclesternomastoid muscle, above clavicle

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Neck vessels: jugular venous pulse and Neck vessels: jugular venous pulse and pressure (cont.)pressure (cont.) Jugular pulse is different Jugular pulse is different

• Results from backwash, a waveform moving backwardResults from backwash, a waveform moving backward Pulse has five components because of events in right side Pulse has five components because of events in right side

of heartof heart

• The A wave reflects atrial contraction because some The A wave reflects atrial contraction because some blood flows backward to vena cava during right atrial blood flows backward to vena cava during right atrial contraction contraction

• The C wave, or ventricular contraction, is backflow from The C wave, or ventricular contraction, is backflow from bulging upward of tricuspid valve when it closes at bulging upward of tricuspid valve when it closes at beginning of ventricular systolebeginning of ventricular systole

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Neck vessels: jugular venous pulse and Neck vessels: jugular venous pulse and pressurepressure (cont.)(cont.) Jugular pulse is different (cont.)Jugular pulse is different (cont.)

• Next, X descent shows atrial relaxation when right Next, X descent shows atrial relaxation when right ventricle contracts during systole and pulls bottom of ventricle contracts during systole and pulls bottom of atria downwardatria downward

• The V wave occurs with passive atrial filling because of The V wave occurs with passive atrial filling because of increasing volume in right atria and increased pressureincreasing volume in right atria and increased pressure

• Finally, the Y descent reflects passive ventricular filling Finally, the Y descent reflects passive ventricular filling when tricuspid valve opens and blood flows from RA to when tricuspid valve opens and blood flows from RA to RVRV

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Structure and Function:Structure and Function:Developmental CompetenceDevelopmental Competence

Infants and childrenInfants and children Fetal heart begins to beat after 3 weeks’ gestationFetal heart begins to beat after 3 weeks’ gestation

• Fetal circulation compensates for nonfunctional lungsFetal circulation compensates for nonfunctional lungs

• Oxygenation takes place at placenta, and arterial blood Oxygenation takes place at placenta, and arterial blood returned to right side of heartreturned to right side of heart

• There is no point in pumping all this freshly oxygenated There is no point in pumping all this freshly oxygenated blood through lungs, so it is rerouted in two waysblood through lungs, so it is rerouted in two ways

First, two thirds of it shunted through an opening in atrial First, two thirds of it shunted through an opening in atrial septum, foramen ovale, into left side of heart, where it is septum, foramen ovale, into left side of heart, where it is pumped out through aortapumped out through aorta

Second, rest of oxygenated blood pumped by right side of Second, rest of oxygenated blood pumped by right side of heart out through pulmonary artery, but is detoured through heart out through pulmonary artery, but is detoured through ductus arteriosus to aortaductus arteriosus to aorta

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(cont.)(cont.) Infants and children (cont.)Infants and children (cont.)

Right and left ventricles equal in weight and Right and left ventricles equal in weight and muscle wall thickness and both pumping into muscle wall thickness and both pumping into systemic circulationsystemic circulation

Inflation and aeration of lungs at birth produces Inflation and aeration of lungs at birth produces circulatory changescirculatory changes

Now blood is oxygenated through lungs rather Now blood is oxygenated through lungs rather than through placentathan through placenta• Foramen ovale closes within first hour because of new Foramen ovale closes within first hour because of new

lower pressure in right side of heart than in left sidelower pressure in right side of heart than in left side

• Ductus arteriosus closes within 10 to 15 hours of birthDuctus arteriosus closes within 10 to 15 hours of birth

Slide 19-46




(cont.)(cont.) Infants and children (cont.)Infants and children (cont.)

Now, left ventricle has greater workload of Now, left ventricle has greater workload of pumping into systemic circulationpumping into systemic circulation• When baby has reached 1 year of age, left ventricle’s When baby has reached 1 year of age, left ventricle’s

mass increases to reach adult ratio of 2:1, left ventricle to mass increases to reach adult ratio of 2:1, left ventricle to right ventricleright ventricle

• Heart’s position in chest is more horizontal in infant than Heart’s position in chest is more horizontal in infant than in adult; thus apex higher, located at fourth left in adult; thus apex higher, located at fourth left intercostal spaceintercostal space

• Reaches adult position when child is age 7 yearsReaches adult position when child is age 7 years

Slide 19-47




(cont.)(cont.) Pregnant womanPregnant woman

Blood volume increases by 30% to 40% during Blood volume increases by 30% to 40% during pregnancypregnancy• Most rapid expansion occurs during second trimesterMost rapid expansion occurs during second trimester

• Creates an increase in stroke volume and cardiac output Creates an increase in stroke volume and cardiac output and an increased pulse rate of 10 to 15 beats per minuteand an increased pulse rate of 10 to 15 beats per minute

• Despite increased cardiac output, arterial blood pressure Despite increased cardiac output, arterial blood pressure decreases in pregnancy as a result of peripheral decreases in pregnancy as a result of peripheral vasodilationvasodilation

• Blood pressure drops to lowest point during second Blood pressure drops to lowest point during second trimester, then rises after thattrimester, then rises after that

• Blood pressure varies with person’s positionBlood pressure varies with person’s position

Slide 19-48




(cont.)(cont.) Aging adultAging adult

It is difficult to isolate “aging process” of It is difficult to isolate “aging process” of cardiovascular system, per se, because it is so cardiovascular system, per se, because it is so closely interrelated with lifestyle, habits, and closely interrelated with lifestyle, habits, and diseasesdiseases• Lifestyle, smoking, diet, alcohol use, exercise patterns, Lifestyle, smoking, diet, alcohol use, exercise patterns,

and stress have an influence on coronary artery diseaseand stress have an influence on coronary artery disease

• Lifestyle also affects aging process; cardiac changes Lifestyle also affects aging process; cardiac changes once thought to be due to aging are partially due to once thought to be due to aging are partially due to sedentary lifestyle accompanying agingsedentary lifestyle accompanying aging

• What is left to be attributed to aging process alone?What is left to be attributed to aging process alone?

Slide 19-49




(cont.)(cont.) Aging adultAging adult (cont.)(cont.)

Hemodynamic changes with agingHemodynamic changes with aging• From age 20 to 60 years, systolic blood pressure From age 20 to 60 years, systolic blood pressure

increases by about 20 mm Hg, and by another 20 mm increases by about 20 mm Hg, and by another 20 mm Hg between ages 60 and 80 yearsHg between ages 60 and 80 years

• This is due to stiffening of large arteries, which, in turn is This is due to stiffening of large arteries, which, in turn is due to calcification of vessel walls (arteriosclerosis)due to calcification of vessel walls (arteriosclerosis)

Creates increase in pulse wave velocity because less Creates increase in pulse wave velocity because less compliant arteries cannot store volume ejectedcompliant arteries cannot store volume ejected

• Overall size of heart does not increase with age, but left Overall size of heart does not increase with age, but left ventricular wall thickness increasesventricular wall thickness increases

An adaptive mechanism to accommodate vascular An adaptive mechanism to accommodate vascular stiffening mentioned earlierstiffening mentioned earlier

Slide 19-50





Hemodynamic changes with aging (cont.)Hemodynamic changes with aging (cont.)• No change in diastolic pressure occurs with ageNo change in diastolic pressure occurs with age

• A rising systolic pressure with a relatively constant A rising systolic pressure with a relatively constant diastolic pressure increases pulse pressure (the diastolic pressure increases pulse pressure (the difference between the two)difference between the two)

• No change in resting heart rate occurs with agingNo change in resting heart rate occurs with aging

• Cardiac output at rest is not changed with agingCardiac output at rest is not changed with aging

• Decreased ability of heart to augment cardiac output with Decreased ability of heart to augment cardiac output with exerciseexercise

• Shown by decreased maximum heart rate with exercise Shown by decreased maximum heart rate with exercise and diminished sympathetic responseand diminished sympathetic response

Slide 19-51





Hemodynamic changes with aging (cont.)Hemodynamic changes with aging (cont.)• Noncardiac factors also cause a decrease in maximum Noncardiac factors also cause a decrease in maximum

work performance with aging: decrease in skeletal work performance with aging: decrease in skeletal muscle performance, increase in muscle fatigue, muscle performance, increase in muscle fatigue, increased sense of dyspneaincreased sense of dyspnea

• Chronic exercise conditioning will modify many of aging Chronic exercise conditioning will modify many of aging changes in cardiovascular functionchanges in cardiovascular function

Slide 19-52





ArrhythmiasArrhythmias• Presence of supraventricular and ventricular arrhythmias Presence of supraventricular and ventricular arrhythmias

increases with ageincreases with age

• Ectopic beats common in aging people; usually Ectopic beats common in aging people; usually asymptomatic in healthy older people, may compromise asymptomatic in healthy older people, may compromise cardiac output and blood pressure when disease presentcardiac output and blood pressure when disease present

• Tachyarrhythmias may not be tolerated as well in older Tachyarrhythmias may not be tolerated as well in older peoplepeople

Myocardium thicker and less compliant, and early diastolic Myocardium thicker and less compliant, and early diastolic filling impaired at restfilling impaired at rest

Thus, may not tolerate a tachycardia as well because of Thus, may not tolerate a tachycardia as well because of shortened diastoleshortened diastole

Slide 19-53





Age-related changes in ECG Age-related changes in ECG • Occur as result of histologic changes in conduction Occur as result of histologic changes in conduction

system; these changes include:system; these changes include: Prolonged P-R interval (first-degree AV block) and Prolonged P-R interval (first-degree AV block) and

prolonged Q-T interval, but the QRS interval is unchangedprolonged Q-T interval, but the QRS interval is unchanged Left axis deviation from age-related mild LV hypertrophy Left axis deviation from age-related mild LV hypertrophy

and fibrosis in left bundle branchand fibrosis in left bundle branch Increased incidence of bundle branch blockIncreased incidence of bundle branch block

• Although hemodynamic changes associated with aging Although hemodynamic changes associated with aging alone do not seem severe or portentous, incidence of alone do not seem severe or portentous, incidence of cardiovascular disease increases with agecardiovascular disease increases with age

Slide 19-54





Incidence of coronary artery disease increases Incidence of coronary artery disease increases sharply with advancing age and accounts for sharply with advancing age and accounts for about half of deaths of older peopleabout half of deaths of older people• Hypertension and heart failure also increase with ageHypertension and heart failure also increase with age

• Lifestyle habits play a significant role in the acquisition of Lifestyle habits play a significant role in the acquisition of heart diseaseheart disease

Also, increasing physical activity of older adults Also, increasing physical activity of older adults associated with a reduced risk of death from associated with a reduced risk of death from cardiovascular diseases and respiratory illnessescardiovascular diseases and respiratory illnesses• Both points underscore need for health teaching as an Both points underscore need for health teaching as an

important treatment parameterimportant treatment parameterSlide 19-55



Structure and Function:Structure and Function:Cultural CompetenceCultural Competence

Prevalence is an estimate of how many Prevalence is an estimate of how many people in a stated geographic location have a people in a stated geographic location have a disease at a given timedisease at a given time

• In the U.S., more than 1 in 3 have one or more forms of In the U.S., more than 1 in 3 have one or more forms of cardiovascular heart disease (CVD)cardiovascular heart disease (CVD)

Annual rates of first CVD event increase with age Annual rates of first CVD event increase with age For women comparable rates occur 10 years later in life For women comparable rates occur 10 years later in life

than for men, but this gap narrows with advancing agethan for men, but this gap narrows with advancing age

• Causes of CVD include interaction of genetic, Causes of CVD include interaction of genetic, environmental, and lifestyle factorsenvironmental, and lifestyle factors

• Evidence shows potentially modifiable risk factors Evidence shows potentially modifiable risk factors contribute to overwhelming majority of cardiac riskcontribute to overwhelming majority of cardiac risk

Slide 19-56



Structure and Function:Structure and Function:Cultural CompetenceCultural Competence (cont.)(cont.)

Although all adults have some potential CVD risk, Although all adults have some potential CVD risk, some groups, defined by race, ethnicity, gender, some groups, defined by race, ethnicity, gender, socioeconomic status, and educational level carry socioeconomic status, and educational level carry an excess burden of CVDan excess burden of CVD• Higher percent of men than women have hypertension Higher percent of men than women have hypertension

until 45 years, after which the percentages are similaruntil 45 years, after which the percentages are similar After 64 years, women have much higher percentage than After 64 years, women have much higher percentage than

menmen

• Hypertension is 2 to 3 times more common among Hypertension is 2 to 3 times more common among women taking oral contraceptives, especially obese and women taking oral contraceptives, especially obese and older womenolder women

• Hypertension in African Americans is among highest in Hypertension in African Americans is among highest in world and is risingworld and is rising

Slide 19-57




HypertensionHypertension Prevalence of hypertension is 31.8% for African Prevalence of hypertension is 31.8% for African

AmericansAmericans 25.3% for American Indians or Alaska Natives25.3% for American Indians or Alaska Natives 23.3% for whites23.3% for whites 21% for Hispanics and Asians21% for Hispanics and Asians Compared with whites, African Americans develop Compared with whites, African Americans develop

hypertension earlier in life and their average BPs hypertension earlier in life and their average BPs are much higherare much higher• Thus, African Americans have greater rate of stroke, death Thus, African Americans have greater rate of stroke, death

due from heart disease, and end-stage kidney diseasedue from heart disease, and end-stage kidney disease

Slide 19-58




SmokingSmoking In the 40+ years from 1965 to 2004, U.S. smoking In the 40+ years from 1965 to 2004, U.S. smoking

rates declined by 50.4% among adults over 18rates declined by 50.4% among adults over 18 In 2008, 23.1% of men and 18.3% of women were In 2008, 23.1% of men and 18.3% of women were

smokerssmokers Nicotine increases risk of myocardial infarction Nicotine increases risk of myocardial infarction

(MI) and stroke by causing:(MI) and stroke by causing:• Increase in oxygen demand with a concomitant decrease Increase in oxygen demand with a concomitant decrease

in oxygen supply in oxygen supply

• Activation of platelets, activation of fibrinogen; and an Activation of platelets, activation of fibrinogen; and an adverse change in lipid profileadverse change in lipid profile

Slide 19-59




Serum cholesterolSerum cholesterol High levels of low density lipoprotein gradually add High levels of low density lipoprotein gradually add

to lipid core of thrombus formation in arteries, to lipid core of thrombus formation in arteries, which results in MI and strokewhich results in MI and stroke

Age adjusted prevalence of total cholesterol levels Age adjusted prevalence of total cholesterol levels over 200 mg/dl areover 200 mg/dl are• 51.1% of Mexican American men and 49% of Mexican 51.1% of Mexican American men and 49% of Mexican

American women American women

• 45% of white men and 48.7% of white women 45% of white men and 48.7% of white women

• 40.2% of African American men and 41.8% of African 40.2% of African American men and 41.8% of African American women American women

Slide 19-60




Type II diabetes mellitus (DM)Type II diabetes mellitus (DM) Risk of CVD is 2-fold greater among persons with Risk of CVD is 2-fold greater among persons with

DMDM• Increased prevalence of DM in U.S. is being followed by Increased prevalence of DM in U.S. is being followed by

an increasing prevalence of CVD morbidity and mortality an increasing prevalence of CVD morbidity and mortality

• Diabetes causes damage to large blood vessels that Diabetes causes damage to large blood vessels that nourish brain, heart and extremities; this results in nourish brain, heart and extremities; this results in stroke, coronary artery disease, and peripheral vascular stroke, coronary artery disease, and peripheral vascular diseasedisease

• About 13% of African Americans over 20 have DMAbout 13% of African Americans over 20 have DM

• 11.8% to 13.1% of Mexican Americans have DM, 11.8% to 13.1% of Mexican Americans have DM, compared to 6.4% of whitescompared to 6.4% of whites

Slide 19-61




ObesityObesity Epidemic of obesity in U.S. is well knownEpidemic of obesity in U.S. is well known

• Among Americans age 20 or older, prevalence of Among Americans age 20 or older, prevalence of overweight or obesity isoverweight or obesity is

74.8% of Mexican American men and 73% of Mexican 74.8% of Mexican American men and 73% of Mexican American womenAmerican women

73.7% of African American men and 77.7% of African 73.7% of African American men and 77.7% of African American womenAmerican women

72.4% of white men and 57.5% of white women72.4% of white men and 57.5% of white women

Slide 19-62



Subjective DataSubjective Data

Chest painChest pain DyspneaDyspnea OrthopneaOrthopnea CoughCough FatigueFatigue Cyanosis or pallorCyanosis or pallor EdemaEdema

NocturiaNocturia Past cardiac historyPast cardiac history Family cardiac Family cardiac

historyhistory Personal habits Personal habits

(cardiac risk factors)(cardiac risk factors)

Slide 19-63



Subjective DataSubjective Data (cont.)(cont.)

Chest painChest pain Any chest pain or tightness?Any chest pain or tightness?

• Onset: When did it start? How long have you had it this Onset: When did it start? How long have you had it this time? Had this type of pain before? How often?time? Had this type of pain before? How often?

• Location: Where did the pain start? Does the pain radiate Location: Where did the pain start? Does the pain radiate to any other spot?to any other spot?

• Character: How would you describe it? Is it crushing, Character: How would you describe it? Is it crushing, stabbing, burning, or viselike? (Allow the person to offer stabbing, burning, or viselike? (Allow the person to offer adjectives before you suggest them.) (Note if uses adjectives before you suggest them.) (Note if uses clenched fist to describe pain.)clenched fist to describe pain.)

• Is pain brought on by activity (what type), rest, emotional Is pain brought on by activity (what type), rest, emotional upset, eating, sexual intercourse, or cold weather?upset, eating, sexual intercourse, or cold weather?

Slide 19-64




Chest pain (cont.)Chest pain (cont.) Any associated symptoms, such as sweating, Any associated symptoms, such as sweating,

ashen gray or pale skin, heart skipping a beat, ashen gray or pale skin, heart skipping a beat, shortness of breath, nausea or vomiting, or racing shortness of breath, nausea or vomiting, or racing of heart? of heart? • Is the pain made worse by moving the arms or neck, Is the pain made worse by moving the arms or neck,

breathing, or lying flat?breathing, or lying flat?

• Is the pain relieved by rest or nitroglycerin? How many Is the pain relieved by rest or nitroglycerin? How many tablets?tablets?

Slide 19-65




DyspneaDyspnea Any shortness of breath?Any shortness of breath?

• What type of activity and how much brings on shortness What type of activity and how much brings on shortness of breath? How much activity brought it on 6 months ago?of breath? How much activity brought it on 6 months ago?

• Onset: Does the shortness of breath come on Onset: Does the shortness of breath come on unexpectedly?unexpectedly?

• Duration: Is it constant or does it come and go?Duration: Is it constant or does it come and go?

• Does it seem to be affected by position, such as lying Does it seem to be affected by position, such as lying down?down?

• Does it awaken you from sleep at night?Does it awaken you from sleep at night?

• Does the shortness of breath interfere with activities of Does the shortness of breath interfere with activities of daily living?daily living?

Slide 19-66




CoughCough Do you have a cough?Do you have a cough?

• Duration: How long have you had it?Duration: How long have you had it?

• Frequency: Is it related to time of day?Frequency: Is it related to time of day?

• Type: Is it dry, hacking, barky, hoarse, or congested?Type: Is it dry, hacking, barky, hoarse, or congested?

• Do you cough up mucus? What color is it? Does it have Do you cough up mucus? What color is it? Does it have any odor? Is it blood tinged?any odor? Is it blood tinged?

• Associated with activity, position (lying down), anxiety, or Associated with activity, position (lying down), anxiety, or talking?talking?

• Does activity make it better or worse (sit, walk, Does activity make it better or worse (sit, walk, exercise)?exercise)?

• Is it relieved by rest or medication?Is it relieved by rest or medication?

Slide 19-67




OrthopneaOrthopnea How many pillows do you use when sleeping or How many pillows do you use when sleeping or

lying down?lying down? Cyanosis or pallorCyanosis or pallor

Have you ever noticed your facial skin turn blue or Have you ever noticed your facial skin turn blue or ashen?ashen?

Slide 19-68




EdemaEdema Do you have any swelling of your feet and legs?Do you have any swelling of your feet and legs?

• Onset: When did you first notice this? Any recent Onset: When did you first notice this? Any recent change?change?

• What time of day does the swelling occur? Do your What time of day does the swelling occur? Do your shoes feel tight at the end of day?shoes feel tight at the end of day?

• How much swelling would you say there is? Are both How much swelling would you say there is? Are both legs equally swollen?legs equally swollen?

• Does swelling go away with rest, elevation, or after a Does swelling go away with rest, elevation, or after a night’s sleep?night’s sleep?

• Do you have any associated symptoms, such as Do you have any associated symptoms, such as shortness of breath? If so, does shortness of breath shortness of breath? If so, does shortness of breath occur before leg swelling or after?occur before leg swelling or after?

Slide 19-69




Cardiac historyCardiac history Do you have a history of hypertension, elevated Do you have a history of hypertension, elevated

cholesterol or triglycerides, heart murmur, cholesterol or triglycerides, heart murmur, congenital heart disease, rheumatic fever or congenital heart disease, rheumatic fever or unexplained joint pains as child or youth, recurrent unexplained joint pains as child or youth, recurrent tonsillitis, or anemia?tonsillitis, or anemia?

Have you ever had heart disease? When was Have you ever had heart disease? When was this? Was it treated by medication or heart this? Was it treated by medication or heart surgery?surgery?

When was your last ECG, stress ECG, serum When was your last ECG, stress ECG, serum cholesterol measurement, or other heart tests?cholesterol measurement, or other heart tests?

Slide 19-70




NocturiaNocturia Do you awaken at night with an urgent need to Do you awaken at night with an urgent need to

urinate? How long has this been occurring? Any urinate? How long has this been occurring? Any recent change?recent change?

Family cardiac historyFamily cardiac history Any family history of hypertension, obesity, Any family history of hypertension, obesity,

diabetes, coronary artery disease (CAD), sudden diabetes, coronary artery disease (CAD), sudden death at younger age?death at younger age?

Slide 19-71




Personal habits (cardiac risk factors)Personal habits (cardiac risk factors) NutritionNutrition

• Please describe your usual daily diet (Note if this diet is Please describe your usual daily diet (Note if this diet is representative of the basic food groups, the amount of representative of the basic food groups, the amount of calories, cholesterol, and any additives such as salt) calories, cholesterol, and any additives such as salt)

• What is your usual weight? Has there been any recent What is your usual weight? Has there been any recent change?change?

SmokingSmoking• Do you smoke cigarettes or use other tobacco products? Do you smoke cigarettes or use other tobacco products?

At what age did you start? How many packs per day? At what age did you start? How many packs per day? For how many years have you smoked this amount? For how many years have you smoked this amount? Have you ever tried to quit? If so, how did this go?Have you ever tried to quit? If so, how did this go?

Slide 19-72




Personal habits (cardiac risk factors) (cont.)Personal habits (cardiac risk factors) (cont.) AlcoholAlcohol

• How much alcohol do you usually drink each day or How much alcohol do you usually drink each day or week? When was your last drink? What was the number week? When was your last drink? What was the number of drinks that episode? Have you ever been told you had of drinks that episode? Have you ever been told you had a drinking problem?a drinking problem?

ExerciseExercise• What is your usual amount of exercise each day or What is your usual amount of exercise each day or

week? What type of exercise (state type or sport)? If a week? What type of exercise (state type or sport)? If a sport, what is your usual activity level (light, moderate, sport, what is your usual activity level (light, moderate, heavy)?heavy)?

Slide 19-73




Personal habits (cardiac risk factors) (cont.)Personal habits (cardiac risk factors) (cont.) DrugsDrugs

• Do you take any antihypertensives, beta-blockers, Do you take any antihypertensives, beta-blockers, calcium channel blockers, digoxin, diuretics, calcium channel blockers, digoxin, diuretics, aspirin/anticoagulants, over-the-counter, or street drugs?aspirin/anticoagulants, over-the-counter, or street drugs?

Slide 19-74




Additional history for infantsAdditional history for infants How was mother’s health during pregnancy? Was How was mother’s health during pregnancy? Was

there any unexplained fever, rubella during first there any unexplained fever, rubella during first trimester, other infection, hypertension, or drugs trimester, other infection, hypertension, or drugs taken?taken?• Have you noted any cyanosis while nursing or crying? Is Have you noted any cyanosis while nursing or crying? Is

baby able to eat, nurse, or finish bottle without tiring?baby able to eat, nurse, or finish bottle without tiring?

• Growth: Has this baby grown as expected by growth Growth: Has this baby grown as expected by growth charts and about same as siblings or peers?charts and about same as siblings or peers?

• Activity: Were this baby’s motor milestones achieved as Activity: Were this baby’s motor milestones achieved as expected? Is baby able to play without tiring? How many expected? Is baby able to play without tiring? How many naps does baby take each day? How long does a nap naps does baby take each day? How long does a nap last?last?

Slide 19-75




Additional history for childrenAdditional history for children Growth: Has this child grown as expected by Growth: Has this child grown as expected by

growth charts?growth charts? Activity: Is this child able to keep up with siblings Activity: Is this child able to keep up with siblings

or age mates? or age mates? • Is the child willing or reluctant to go out to play? Is the child willing or reluctant to go out to play?

• Is the child able to climb stairs, ride a bike, walk a few Is the child able to climb stairs, ride a bike, walk a few blocks? blocks?

• Does the child squat to rest during play or to watch Does the child squat to rest during play or to watch television, or assume a knee-chest position while television, or assume a knee-chest position while sleeping? Have you noted “blue spells” during exercise?sleeping? Have you noted “blue spells” during exercise?

Slide 19-76




Additional history for children (cont.)Additional history for children (cont.) Has the child had any unexplained joint pains or Has the child had any unexplained joint pains or

unexplained fever?unexplained fever? Does the child have frequent headaches or Does the child have frequent headaches or

nosebleeds?nosebleeds? Does the child have frequent respiratory Does the child have frequent respiratory

infections? How many per year? How are they infections? How many per year? How are they treated? Have any of these been streptococcal treated? Have any of these been streptococcal infections?infections?

Slide 19-77




Additional history for children (cont.)Additional history for children (cont.) Family historyFamily history

• Does child have a sibling with heart defect? Is anyone in Does child have a sibling with heart defect? Is anyone in child’s family known to have chromosomal abnormalities, child’s family known to have chromosomal abnormalities, such as Down syndrome?such as Down syndrome?

Slide 19-78




Additional history for pregnant womanAdditional history for pregnant woman Have you had any high blood pressure during this Have you had any high blood pressure during this

or earlier pregnancies?or earlier pregnancies?• What was your usual blood pressure level before What was your usual blood pressure level before

pregnancy? How has your blood pressure been pregnancy? How has your blood pressure been monitored during the pregnancy?monitored during the pregnancy?

• If high blood pressure, what treatment has been started?If high blood pressure, what treatment has been started?

• Do you have any associated symptoms, such as weight Do you have any associated symptoms, such as weight gain, protein in urine, or swelling in feet, legs, or face?gain, protein in urine, or swelling in feet, legs, or face?

Have you had any faintness or dizziness with this Have you had any faintness or dizziness with this pregnancy?pregnancy?

Slide 19-79




Additional history for aging adultAdditional history for aging adult Do you have any known heart or lung disease, Do you have any known heart or lung disease,

such as hypertension, CAD, chronic emphysema, such as hypertension, CAD, chronic emphysema, or bronchitis?or bronchitis?• What efforts to treat this have been started?What efforts to treat this have been started?

• What usual symptoms changed recently? Does your What usual symptoms changed recently? Does your illness interfere with activities of daily living?illness interfere with activities of daily living?

Do you take any medications for your illness such Do you take any medications for your illness such as digitalis? Are you aware of side effects? Have as digitalis? Are you aware of side effects? Have you recently stopped taking your medication? you recently stopped taking your medication? Why?Why?

Slide 19-80




Additional history for aging adult (cont.)Additional history for aging adult (cont.) EnvironmentEnvironment

• Does your home have any stairs? How often do you Does your home have any stairs? How often do you need to climb them? Does this have any effect on need to climb them? Does this have any effect on activities of daily living?activities of daily living?

Slide 19-81



Objective DataObjective Data (cont.)(cont.)

PreparationPreparation To evaluate carotid arteries, person can be sitting To evaluate carotid arteries, person can be sitting To assess jugular veins and precordium, person To assess jugular veins and precordium, person

should be supine with head and chest slightly should be supine with head and chest slightly elevatedelevated• Stand on the person’s right side; this will facilitate your Stand on the person’s right side; this will facilitate your

hand placement and auscultation of precordiumhand placement and auscultation of precordium

• Room must be warm, chilling makes person Room must be warm, chilling makes person uncomfortable, and shivering interferes with heart uncomfortable, and shivering interferes with heart soundssounds

• Take scrupulous care to ensure quiet; heart sounds are Take scrupulous care to ensure quiet; heart sounds are very soft, and any ambient room noise masks themvery soft, and any ambient room noise masks them

Slide 19-82




Preparation (cont.)Preparation (cont.) Ensure woman’s privacy by keeping her breasts Ensure woman’s privacy by keeping her breasts

drapeddraped• Woman’s left breast overrides part of area you will need Woman’s left breast overrides part of area you will need

to examine; gently displace breast upward, or ask to examine; gently displace breast upward, or ask woman to hold it out of waywoman to hold it out of way

• When performing a regional cardiovascular assessment, When performing a regional cardiovascular assessment, use this order: pulse and blood pressure, extremities, use this order: pulse and blood pressure, extremities, neck vessels, precordiumneck vessels, precordium

• Logic of this order is that you begin observations Logic of this order is that you begin observations peripherally and move in toward heartperipherally and move in toward heart

Slide 19-83




Equipment neededEquipment needed Marking penMarking pen Small centimeter rulerSmall centimeter ruler Stethoscope with diaphragm and bell endpiecesStethoscope with diaphragm and bell endpieces Alcohol wipe to clean endpieceAlcohol wipe to clean endpiece

Slide 19-84




Neck vesselsNeck vessels Palpate carotid arteryPalpate carotid artery

• Yields important information on cardiac functionYields important information on cardiac function

• Palpate each carotid artery medial to sternomastoid Palpate each carotid artery medial to sternomastoid muscle in neck; palpate gentlymuscle in neck; palpate gently

• Palpate only one carotid artery at a time to avoid Palpate only one carotid artery at a time to avoid compromising arterial blood to braincompromising arterial blood to brain

• Feel contour and amplitude of pulseFeel contour and amplitude of pulse

• Normally contour is smooth with a rapid upstroke and Normally contour is smooth with a rapid upstroke and slower downstroke, and the normal strength is 2+ or slower downstroke, and the normal strength is 2+ or moderatemoderate

• Findings should be same bilaterallyFindings should be same bilaterally

Slide 19-85




Neck vessels (cont.)Neck vessels (cont.) Auscultate carotid arteryAuscultate carotid artery

• For persons middle-aged or older, or who show For persons middle-aged or older, or who show symptoms or signs of cardiovascular disease, auscultate symptoms or signs of cardiovascular disease, auscultate each carotid artery for presence of a bruiteach carotid artery for presence of a bruit

This is a blowing, swishing sound indicating blood flow This is a blowing, swishing sound indicating blood flow turbulence; normally none is presentturbulence; normally none is present

• Lightly apply bell of stethoscope over carotid artery at Lightly apply bell of stethoscope over carotid artery at three levels: three levels:

Angle of jawAngle of jaw Midcervical areaMidcervical area Base of neckBase of neck

Slide 19-86




Neck vesselsNeck vessels Auscultate carotid artery (cont.)Auscultate carotid artery (cont.)

• Avoid compressing artery because this could create an Avoid compressing artery because this could create an artificial bruit, and could compromise circulation if carotid artificial bruit, and could compromise circulation if carotid artery is already narrowed by atherosclerosisartery is already narrowed by atherosclerosis

• Ask person to take a breath, exhale, and hold it briefly Ask person to take a breath, exhale, and hold it briefly while you listen so that tracheal breath sounds do not while you listen so that tracheal breath sounds do not mask or mimic a carotid artery bruitmask or mimic a carotid artery bruit

Holding breath on inhalation will also tense levator Holding breath on inhalation will also tense levator scapulae muscles, which makes it hard to hear carotids scapulae muscles, which makes it hard to hear carotids

• Sometimes you can hear normal heart sounds Sometimes you can hear normal heart sounds transmitted to neck; do not confuse these with a bruittransmitted to neck; do not confuse these with a bruit

Slide 19-87




Neck vessels (cont.)Neck vessels (cont.) Inspect jugular venous pulseInspect jugular venous pulse

• From jugular veins you can assess central venous From jugular veins you can assess central venous pressure (CVP) and judge heart’s efficiency as a pumppressure (CVP) and judge heart’s efficiency as a pump

Although external jugular vein is easier to see, internal Although external jugular vein is easier to see, internal (especially the right) jugular vein is attached more directly (especially the right) jugular vein is attached more directly to superior vena cava and more reliable for assessmentto superior vena cava and more reliable for assessment

You cannot see internal jugular vein itself, but you can see You cannot see internal jugular vein itself, but you can see its pulsationits pulsation

• Position person supine anywhere from a 30- to a 45-Position person supine anywhere from a 30- to a 45-degree angle, wherever you can best see pulsationsdegree angle, wherever you can best see pulsations

• In general, the higher the venous pressure, the higher In general, the higher the venous pressure, the higher the position you needthe position you need

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Neck vesselsNeck vessels (cont.)(cont.) Inspect jugular venous pulse (cont.)Inspect jugular venous pulse (cont.)

• Look for pulsations of internal jugular veins in area of Look for pulsations of internal jugular veins in area of suprasternal notch or around origin of sternomastoid suprasternal notch or around origin of sternomastoid muscle around claviclemuscle around clavicle

• You must be able to distinguish internal jugular vein You must be able to distinguish internal jugular vein pulsation from that of carotid arterypulsation from that of carotid artery

• It is easy to confuse them because they lie close It is easy to confuse them because they lie close togethertogether

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Neck vessels (cont.)Neck vessels (cont.) Estimate jugular venous pressureEstimate jugular venous pressure

• Use angle of Louis as arbitrary reference point, and Use angle of Louis as arbitrary reference point, and compare it with highest level of venous pulsationcompare it with highest level of venous pulsation

• Hold a vertical ruler on sternal angleHold a vertical ruler on sternal angle

• Align a straight edge on ruler like a T-square, and adjust Align a straight edge on ruler like a T-square, and adjust level of horizontal straight edge to level of pulsationlevel of horizontal straight edge to level of pulsation

• Read level of intersection on vertical ruler; normal jugular Read level of intersection on vertical ruler; normal jugular venous pulsation is 2 cm or less above sternal anglevenous pulsation is 2 cm or less above sternal angle

• State person’s position, e.g., “internal jugular vein State person’s position, e.g., “internal jugular vein pulsations 3 cm above sternal angle when elevated 30 pulsations 3 cm above sternal angle when elevated 30 degrees”degrees”

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Neck vesselsNeck vessels (cont.)(cont.) Estimate jugular venous pressure (cont.)Estimate jugular venous pressure (cont.)

• If you cannot find internal jugular veins, use external If you cannot find internal jugular veins, use external jugular veins and note point where they look collapsedjugular veins and note point where they look collapsed

• If venous pressure is elevated, or if you suspect heart If venous pressure is elevated, or if you suspect heart failure, perform hepatojugular refluxfailure, perform hepatojugular reflux

Position person comfortably supine and instruct him or her Position person comfortably supine and instruct him or her to breathe quietly through open mouthto breathe quietly through open mouth

• Hold your right hand on right upper quadrant of person’s Hold your right hand on right upper quadrant of person’s abdomen just below rib cageabdomen just below rib cage

• Watch level of jugular pulsation as you push in with your Watch level of jugular pulsation as you push in with your handhand

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Neck vesselsNeck vessels (cont.)(cont.) Estimate jugular venous pressure (cont.)Estimate jugular venous pressure (cont.)

• Exert firm sustained pressure for 30 secondsExert firm sustained pressure for 30 seconds

• This empties venous blood out of liver sinusoids and This empties venous blood out of liver sinusoids and adds its volume to venous systemadds its volume to venous system

• If heart is able to pump this additional volume (i.e., if no If heart is able to pump this additional volume (i.e., if no elevated CVP is present), jugular veins will rise for a few elevated CVP is present), jugular veins will rise for a few seconds, then recede back to previous levelseconds, then recede back to previous level

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Neck VesselsNeck Vessels

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Objective DataObjective Data

PrecordiumPrecordium Inspect anterior chestInspect anterior chest

• Arrange tangential lighting to accentuate any flicker of Arrange tangential lighting to accentuate any flicker of movementmovement

• Pulsations: you may or may not see apical impulse, Pulsations: you may or may not see apical impulse, pulsation created as left ventricle rotates against chest pulsation created as left ventricle rotates against chest wall during systolewall during systole

When visible, it occupies the fourth or fifth intercostal When visible, it occupies the fourth or fifth intercostal space, at or inside midclavicular linespace, at or inside midclavicular line

Easier to see in children and in those with thinner chest Easier to see in children and in those with thinner chest wallswalls

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PrecordiumPrecordium (cont.)(cont.) Palpate apical impulsePalpate apical impulse

• Localize apical impulse precisely by using one finger pad Localize apical impulse precisely by using one finger pad

• Asking person to “exhale and then hold it” aids examiner Asking person to “exhale and then hold it” aids examiner in locating pulsation; may need to roll person midway to in locating pulsation; may need to roll person midway to left to find it; note that this also displaces apical impulse left to find it; note that this also displaces apical impulse farther to leftfarther to left

• Palpable in about half of adults; is not palpable in obese Palpable in about half of adults; is not palpable in obese persons or in persons with thick chest wallspersons or in persons with thick chest walls

• With high cardiac output states (anxiety, fever, With high cardiac output states (anxiety, fever, hyperthyroidism, anemia), apical impulse increases in hyperthyroidism, anemia), apical impulse increases in amplitude and durationamplitude and duration

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PrecordiumPrecordium (cont.)(cont.) Palpate across precordiumPalpate across precordium

• Using palmar aspects of your four fingers, gently palpate Using palmar aspects of your four fingers, gently palpate apex, left sternal border, and base, searching for any apex, left sternal border, and base, searching for any other pulsations other pulsations

• Normally none occurNormally none occur

• If any are present, note timingIf any are present, note timing

• Use carotid artery pulsation as a guide, or auscultate as Use carotid artery pulsation as a guide, or auscultate as you palpateyou palpate

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PrecordiumPrecordium (cont.)(cont.) PercussionPercussion

• Used to outline heart’s borders, but its use has often Used to outline heart’s borders, but its use has often been displaced by chest x-ray or echocardiogrambeen displaced by chest x-ray or echocardiogram

• Much more accurate in detecting heart enlargementMuch more accurate in detecting heart enlargement

• When right ventricle enlarges, it does so in When right ventricle enlarges, it does so in anteroposterior diameter, which is better seen on x-ray anteroposterior diameter, which is better seen on x-ray filmfilm

• Also, percussion is of limited usefulness with female Also, percussion is of limited usefulness with female breast tissue or in an obese person or a person with a breast tissue or in an obese person or a person with a muscular chest wallmuscular chest wall

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PrecordiumPrecordium (cont.)(cont.) PercussionPercussion (cont.)(cont.)

• There are times when your percussing hands are only There are times when your percussing hands are only tools you have with youtools you have with you

• When you need to search for cardiac enlargement, place When you need to search for cardiac enlargement, place your stationary finger in person’s fifth intercostal space your stationary finger in person’s fifth intercostal space over on left side of chest near anterior axillary lineover on left side of chest near anterior axillary line

• Slide your stationary hand toward yourself, percussing Slide your stationary hand toward yourself, percussing as you go, and note change of sound from resonance as you go, and note change of sound from resonance over lung to dull over heartover lung to dull over heart

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PrecordiumPrecordium (cont.)(cont.) Percussion (cont.)Percussion (cont.)

• Normally, left border of cardiac dullness at midclavicular Normally, left border of cardiac dullness at midclavicular line in fifth interspace and slopes in toward sternum as line in fifth interspace and slopes in toward sternum as you progress upward, so that by second interspace you progress upward, so that by second interspace border of dullness coincides with the left sternal borderborder of dullness coincides with the left sternal border

• Right border of dullness normally matches sternal borderRight border of dullness normally matches sternal border

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PrecordiumPrecordium (cont.)(cont.) AuscultationAuscultation

• Identify auscultatory areas where you will listen; these Identify auscultatory areas where you will listen; these include four traditional valve “areas” include four traditional valve “areas”

Valve areas are not over actual anatomic locations of Valve areas are not over actual anatomic locations of valves but sites on chest wall where sounds produced by valves but sites on chest wall where sounds produced by valves are best heardvalves are best heard

• Sound radiates with blood flow direction; valve areas are:Sound radiates with blood flow direction; valve areas are: Second right interspace: aortic valve areaSecond right interspace: aortic valve area Second left interspace: pulmonic valve areaSecond left interspace: pulmonic valve area Left lower sternal border: tricuspid valve areaLeft lower sternal border: tricuspid valve area Fifth interspace at around left midclavicular line: mitral Fifth interspace at around left midclavicular line: mitral

valve areavalve area

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Auscultatory AreasAuscultatory Areas

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PrecordiumPrecordium (cont.)(cont.) Auscultation (cont.)Auscultation (cont.)

• Do not limit your auscultation to only four locations Do not limit your auscultation to only four locations

• Sounds produced by valves may be heard all over Sounds produced by valves may be heard all over precordiumprecordium

• Thus, learn to inch your stethoscope in a rough Z Thus, learn to inch your stethoscope in a rough Z pattern, from base of heart across and down, then over pattern, from base of heart across and down, then over to apex; or start at apex and work your way upto apex; or start at apex and work your way up

• Although all heart sounds are low frequency, diaphragm Although all heart sounds are low frequency, diaphragm is for relatively higher pitched sounds, and bell is for is for relatively higher pitched sounds, and bell is for relatively lower pitched onesrelatively lower pitched ones

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• Before you begin, alert person that you always listen to Before you begin, alert person that you always listen to heart in a number of places on chest, and just because heart in a number of places on chest, and just because you are listening a long time does not necessarily mean you are listening a long time does not necessarily mean that something is wrongthat something is wrong

• After you place stethoscope, try closing your eyes briefly After you place stethoscope, try closing your eyes briefly to tune out any distractionsto tune out any distractions

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• Concentrate, and listen selectively to one sound at a timeConcentrate, and listen selectively to one sound at a time

• Consider that at least two, and perhaps three or four Consider that at least two, and perhaps three or four sounds may be happening in less than 1 secondsounds may be happening in less than 1 second

• You cannot process everything at onceYou cannot process everything at once

• Begin with diaphragm endpiece and use following routineBegin with diaphragm endpiece and use following routine Note rate and rhythm Note rate and rhythm Identify SIdentify S11 and S and S22

Assess SAssess S11 and S and S22 separately separately Listen for extra heart soundsListen for extra heart sounds Listen for murmursListen for murmurs

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Objective Data:Objective Data:Developmental CompetenceDevelopmental Competence

InfantsInfants Transition from fetal to pulmonic circulation occurs Transition from fetal to pulmonic circulation occurs

in immediate newborn periodin immediate newborn period• Fetal shunts normally close within 10 to 15 hours but Fetal shunts normally close within 10 to 15 hours but

may take up to 48 hours; thus, you should assess may take up to 48 hours; thus, you should assess cardiovascular system during first 24 hours and again in cardiovascular system during first 24 hours and again in 2 to 3 days2 to 3 days

• Note any extracardiac signs that may reflect heart status Note any extracardiac signs that may reflect heart status (particularly in skin), liver size, and respiratory status(particularly in skin), liver size, and respiratory status

• Skin color should be pink to pinkish brown, depending on Skin color should be pink to pinkish brown, depending on infant’s genetic heritage; if cyanosis occurs, determine infant’s genetic heritage; if cyanosis occurs, determine first appearance; at or shortly after birth versus after first appearance; at or shortly after birth versus after neonatal periodneonatal period

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(cont.)(cont.) Infants (cont.)Infants (cont.)

Normally, the liver is not enlarged, and Normally, the liver is not enlarged, and respirations are not laboredrespirations are not labored• Note expected pattern of weight gain throughout infancyNote expected pattern of weight gain throughout infancy

• Palpate apical impulse to fix size and position of heartPalpate apical impulse to fix size and position of heart

• Because infant’s heart has a more horizontal placement, Because infant’s heart has a more horizontal placement, expect to palpate apical impulse at fourth intercostal expect to palpate apical impulse at fourth intercostal space just lateral to midclavicular linespace just lateral to midclavicular line

• Heart rate best auscultated because radial pulses are Heart rate best auscultated because radial pulses are hard to count accurately; use small (pediatric size) hard to count accurately; use small (pediatric size) diaphragm and belldiaphragm and bell

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Heart rate may range from 100 to 180 beats per Heart rate may range from 100 to 180 beats per minute (bpm) immediately after birthminute (bpm) immediately after birth• Then stabilize to an average of 120 to 140 bpm Then stabilize to an average of 120 to 140 bpm

• Infants normally have wide fluctuations with activity, from Infants normally have wide fluctuations with activity, from 170 bpm or more with crying or being active to 70 to 90 170 bpm or more with crying or being active to 70 to 90 bpm with sleepingbpm with sleeping

• Variations are greatest at birth and are even more so Variations are greatest at birth and are even more so with premature babieswith premature babies

• Expect heart rhythm to have sinus arrhythmia, phasic Expect heart rhythm to have sinus arrhythmia, phasic speeding up or slowing down with respiratory cyclespeeding up or slowing down with respiratory cycle

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Rapid rates make it more challenging to evaluate Rapid rates make it more challenging to evaluate heart soundsheart sounds• Expect heart sounds to be louder in infants than in adults Expect heart sounds to be louder in infants than in adults

because of infant’s thinner chest wall.because of infant’s thinner chest wall.

• Also, SAlso, S22 has a higher pitch and is sharper than S has a higher pitch and is sharper than S11

• Splitting of SSplitting of S22 just after height of inspiration is common, just after height of inspiration is common,

not at birth, but beginning a few hours after birthnot at birth, but beginning a few hours after birth

• Murmurs in immediate newborn period do not Murmurs in immediate newborn period do not necessarily indicate congenital heart diseasenecessarily indicate congenital heart disease

• Murmurs are relatively common in first 2 to 3 days Murmurs are relatively common in first 2 to 3 days because of fetal shunt closurebecause of fetal shunt closure

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These murmurs are usually grade i or iiThese murmurs are usually grade i or ii• They are systolic and accompany no other signs of They are systolic and accompany no other signs of

cardiac disease, and they disappear in 2 to 3 dayscardiac disease, and they disappear in 2 to 3 days

• Murmur of patent ductus arteriosis is continuous Murmur of patent ductus arteriosis is continuous machinery murmur, which disappears by 2 to 3 daysmachinery murmur, which disappears by 2 to 3 days

• On other hand, absence of a murmur in immediate On other hand, absence of a murmur in immediate newborn period does not ensure a perfect heartnewborn period does not ensure a perfect heart

• Congenital defects can be present that are not signaled Congenital defects can be present that are not signaled by an early murmurby an early murmur

• Best to listen frequently and to note and describe any Best to listen frequently and to note and describe any murmur according to characteristicsmurmur according to characteristics

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(cont.)(cont.) ChildrenChildren

Note any extracardiac or cardiac signs that may Note any extracardiac or cardiac signs that may indicate heart diseaseindicate heart disease• Poor weight gain, developmental delay, persistent Poor weight gain, developmental delay, persistent

tachycardia, tachypnea, dyspnea on exertion, cyanosis, tachycardia, tachypnea, dyspnea on exertion, cyanosis, and clubbingand clubbing

• Note that clubbing of fingers and toes usually does not Note that clubbing of fingers and toes usually does not appear until late in 1st year, even with severe cyanotic appear until late in 1st year, even with severe cyanotic defectsdefects

• Apical impulse sometimes visible in children with thin Apical impulse sometimes visible in children with thin chest wallschest walls

• Note any obvious bulge or any heave; these are not Note any obvious bulge or any heave; these are not normalnormal

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(cont.)(cont.) Children (cont.)Children (cont.)

Palpate apical impulsePalpate apical impulse• Up to age 4: in fourth intercostal space to left of Up to age 4: in fourth intercostal space to left of

midclavicular linemidclavicular line

• Age 4 to 6: at fourth interspace at midclavicular lineAge 4 to 6: at fourth interspace at midclavicular line

• Age 7: in fifth interspace to right of midclavicular lineAge 7: in fifth interspace to right of midclavicular line

• Average heart rate slows as child grows older, although Average heart rate slows as child grows older, although it is still variable with rest or activityit is still variable with rest or activity

• Rhythm remains characterized by sinus arrhythmia Rhythm remains characterized by sinus arrhythmia

• Physiologic SPhysiologic S33 is common in children is common in children

• Occurs in early diastole, just after SOccurs in early diastole, just after S22, and is a dull soft , and is a dull soft

sound that is best heard at apexsound that is best heard at apex

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(cont.)(cont.) ChildrenChildren (cont.)(cont.)

Palpate apical impulse (cont.)Palpate apical impulse (cont.)• Venous hum, due to turbulence of blood flow in jugular Venous hum, due to turbulence of blood flow in jugular

venous system, common in healthy children and has no venous system, common in healthy children and has no pathologic significancepathologic significance

Continuous, low-pitched, soft hum heard throughout cycle, Continuous, low-pitched, soft hum heard throughout cycle, although loudest in diastolealthough loudest in diastole

Listen with bell over the supraclavicular fossa at medial Listen with bell over the supraclavicular fossa at medial third of clavicle, especially on right, or over upper anterior third of clavicle, especially on right, or over upper anterior chestchest

• Venous hum is usually not affected by respiration, may Venous hum is usually not affected by respiration, may sound louder when the child stands, and is easily sound louder when the child stands, and is easily obliterated by occluding jugular veins in neck with fingersobliterated by occluding jugular veins in neck with fingers

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Palpate apical impulse (cont.)Palpate apical impulse (cont.)• Heart murmurs that are innocent (or functional) in origin Heart murmurs that are innocent (or functional) in origin

are very common through childhoodare very common through childhood

• Some say they have 30% occurrence, and some say Some say they have 30% occurrence, and some say nearly all children may demonstrate murmurnearly all children may demonstrate murmur

• Most innocent murmurs have these characteristics Most innocent murmurs have these characteristics Soft, relatively short systolic ejection murmur Soft, relatively short systolic ejection murmur Medium pitch; vibratory Medium pitch; vibratory Best heard at left lower sternal or midsternal border, with Best heard at left lower sternal or midsternal border, with

no radiation to apex, base, or backno radiation to apex, base, or back

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Palpate apical impulse (cont.)Palpate apical impulse (cont.)• For child whose murmur has been shown to be innocent, For child whose murmur has been shown to be innocent,

it is very important that parents understand completelyit is very important that parents understand completely

• They need to believe that this murmur is just a “noise” They need to believe that this murmur is just a “noise” and has no pathologic significanceand has no pathologic significance

• Otherwise, parents may become overprotective and limit Otherwise, parents may become overprotective and limit activity for child, which may result in child developing a activity for child, which may result in child developing a negative self-conceptnegative self-concept

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(cont.)(cont.) Pregnant womanPregnant woman

Vital signs usually yield an increase in resting Vital signs usually yield an increase in resting pulse rate of 10 to 15 bpm and drop in BP from pulse rate of 10 to 15 bpm and drop in BP from normal prepregnancy levelnormal prepregnancy level• BP decreases to lowest point during second trimester BP decreases to lowest point during second trimester

and then slowly rises during third trimesterand then slowly rises during third trimester

• BP varies with position; usually lowest in left lateral BP varies with position; usually lowest in left lateral recumbent position, a bit higher when supine, and recumbent position, a bit higher when supine, and highest when sittinghighest when sitting

• Inspection of skin often shows a mild hyperemia in light-Inspection of skin often shows a mild hyperemia in light-skinned women because increased cutaneous blood flow skinned women because increased cutaneous blood flow tries to eliminate excess heat generated by increased tries to eliminate excess heat generated by increased metabolismmetabolism

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(cont.)(cont.) Pregnant woman (cont.)Pregnant woman (cont.)

Palpation of apical impulse is higher and lateral Palpation of apical impulse is higher and lateral compared with normal positioncompared with normal position• Enlarging uterus elevates diaphragm and displaces heart Enlarging uterus elevates diaphragm and displaces heart

up and to left and rotates it on its long axisup and to left and rotates it on its long axis

• Auscultation of heart sounds shows changes caused by Auscultation of heart sounds shows changes caused by increased blood volume and workloadincreased blood volume and workload

• Heart soundsHeart sounds Exaggerated splitting of SExaggerated splitting of S11 and increased loudness of S and increased loudness of S11

A loud, easily heard SA loud, easily heard S33

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(cont.)(cont.) Pregnant womanPregnant woman (cont.)(cont.)

Palpation of apical impulse (cont.)Palpation of apical impulse (cont.)• Heart murmursHeart murmurs

Systolic murmur in 90% which disappears soon after Systolic murmur in 90% which disappears soon after deliverydelivery

Soft, diastolic murmur heard transiently in 19%Soft, diastolic murmur heard transiently in 19% Continuous murmur from breast vasculature in 10%Continuous murmur from breast vasculature in 10%

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(cont.)(cont.) Pregnant womanPregnant woman (cont.)(cont.)

Palpation of apical impulse (cont.)Palpation of apical impulse (cont.)• Last-mentioned murmur termed a mammary souffle, Last-mentioned murmur termed a mammary souffle,

which occurs near term or when mother is lactatingwhich occurs near term or when mother is lactating

• Due to increased blood flow through internal mammary Due to increased blood flow through internal mammary arteryartery

• Murmur is heard in 2nd, 3rd, or 4th intercostal spaceMurmur is heard in 2nd, 3rd, or 4th intercostal space

• Continuous, although it is accented in systoleContinuous, although it is accented in systole

• You can obliterate it by pressure with stethoscope or one You can obliterate it by pressure with stethoscope or one finger lateral to murmurfinger lateral to murmur

• ECG has no changes except for a slight left axis ECG has no changes except for a slight left axis deviation due to change in heart’s positiondeviation due to change in heart’s position

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(cont.)(cont.) Aging adultAging adult

Gradual rise in systolic blood pressure common Gradual rise in systolic blood pressure common with agingwith aging• Diastolic blood pressure stays fairly constant with a Diastolic blood pressure stays fairly constant with a

resulting widening of pulse pressureresulting widening of pulse pressure

• Some older adults experience orthostatic hypotension, a Some older adults experience orthostatic hypotension, a sudden drop in blood pressure when rising to sit or standsudden drop in blood pressure when rising to sit or stand

• Use caution in palpating and auscultating carotid artery Use caution in palpating and auscultating carotid artery Avoid pressure in carotid sinus area, which could cause a Avoid pressure in carotid sinus area, which could cause a

reflex slowing of heart ratereflex slowing of heart rate Also, pressure on carotid artery could compromise Also, pressure on carotid artery could compromise

circulation if artery is already narrowed by atherosclerosiscirculation if artery is already narrowed by atherosclerosis

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(cont.)(cont.) Aging adult (cont.) Aging adult (cont.)

When measuring jugular venous pressure, view When measuring jugular venous pressure, view right internal jugular veinright internal jugular vein• Aorta stiffens, dilates, and elongates with aging, which Aorta stiffens, dilates, and elongates with aging, which

may compress left neck veins and obscure pulsations on may compress left neck veins and obscure pulsations on the left sidethe left side

• Chest often increases in anteroposterior diameter with Chest often increases in anteroposterior diameter with agingaging

• This makes it more difficult to palpate apical impulse and This makes it more difficult to palpate apical impulse and to hear splitting of Sto hear splitting of S22

• SS44 often occurs in older people with no known cardiac often occurs in older people with no known cardiac

diseasedisease

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(cont.)(cont.) Aging adult (cont.) Aging adult (cont.)

Systolic murmurs common, occurring in over 50% Systolic murmurs common, occurring in over 50% of aging peopleof aging people• Occasional premature ectopic beats are common and do Occasional premature ectopic beats are common and do

not necessarily indicate underlying heart diseasenot necessarily indicate underlying heart disease

• When in doubt, obtain an ECGWhen in doubt, obtain an ECG

• However, consider that ECG only records for one However, consider that ECG only records for one isolated minute in time and may need to be isolated minute in time and may need to be supplemented by a test of 24-hour ambulatory heart supplemented by a test of 24-hour ambulatory heart monitoringmonitoring

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Sample chartingSample charting

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Sample chartingSample charting (cont.) (cont.)

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Abnormal Findings:Abnormal Findings:Systolic Extra SoundsSystolic Extra Sounds

Ejection clickEjection click Aortic prosthetic valve soundsAortic prosthetic valve sounds Midsystolic clickMidsystolic click

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Abnormal Findings:Abnormal Findings:Diastolic Extra SoundsDiastolic Extra Sounds

Opening snapOpening snap Mitral prosthetic valve soundMitral prosthetic valve sound Third heart soundThird heart sound Fourth heart soundFourth heart sound Summation soundSummation sound Pericardial friction rubPericardial friction rub

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Abnormal Findings:Abnormal Findings:Abnormal Pulsations: PrecordiumAbnormal Pulsations: Precordium Thrill at the baseThrill at the base Lift (heave) at the sternal borderLift (heave) at the sternal border Volume overload at the apexVolume overload at the apex Pressure overload at the apex Pressure overload at the apex

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Abnormal Findings:Abnormal Findings:Congenital Heart DefectsCongenital Heart Defects

Patent ductus arteriosusPatent ductus arteriosus Atrial septal defectAtrial septal defect Ventricular septal defectVentricular septal defect Tetralogy of FallotTetralogy of Fallot Coarctation of the aortaCoarctation of the aorta

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Abnormal Findings:Abnormal Findings:Murmurs Due to Valvular DefectsMurmurs Due to Valvular Defects

Midsystolic ejection murmursMidsystolic ejection murmurs Aortic stenosisAortic stenosis Pulmonic stenosisPulmonic stenosis

Pansystolic regurgitant murmursPansystolic regurgitant murmurs

Mitral regurgitationMitral regurgitation Tricuspid regurgitationTricuspid regurgitation

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Abnormal Findings:Abnormal Findings:Murmurs Due to Valvular DefectsMurmurs Due to Valvular Defects

Diastolic rumbles of atrioventricular valvesDiastolic rumbles of atrioventricular valves Mitral stenosisMitral stenosis Tricuspid stenosisTricuspid stenosis

Early diastolic murmursEarly diastolic murmurs

Aortic regurgitationAortic regurgitation Pulmonic regurgitationPulmonic regurgitation

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Heart and Neck Vessels

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