The Cardio Vascular

Chapter 9
The Cardiovascular System
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Cardiovascular System:
Examining the Heart and Blood Vessels
• Overview
– Anatomy of the heart and great vessels
– The heart as a pump; blood pressure
– Beginning the examination with the vital signs: blood
pressure and heart rate
– Jugular venous pressure (JVP) and pulsations;
carotid pulse
– Chest wall and apical impulse/PMI
– Auscultation: S1 and S2; S3 and S4
– Auscultation: describing cardiac murmurs
The Heart and Great Vessels: Anatomy

Know Your Surface Landmarks
• Count interspaces
– Identify your ...
o Midsternal line
o Midclavicular line
o Anterior axillary line
o Midaxillary line

Visualize the Chambers of the Heart and
Important Great Vessels
• Visualize the circulation through the:

– Superior and inferior vena cavas
– Right atrium and the right ventricle
– Pulmonary arteries
– Left atrium and left ventricle
– Aorta and the aortic arch

The Heart as a Pump:
Key Points for Examining the Heart
• Note the heart chambers and valves and the

forward flow of blood from the right side of the
heart through the pulmonary arteries and veins to
the left side of the heart
• Combine this knowledge with careful examination
and systematic clinical reasoning
– This will lead you to correct identification of
valvular and congestive heart disease

The Heart as a Pump:
The Cardiac Cycle of Systole and Diastole
• Systole: the ventricles contract
– The right ventricle pumps blood into the pulmonary
arteries (pulmonic valve is open)
– The left ventricle pumps blood into the aorta
(aortic valve is open)
• Diastole: the ventricles relax
– Blood flows from the right atrium → right ventricle
(tricuspid valve is open)
– Blood flows from the left atrium → left ventricle
(mitral valve is open)
The Heart as a Pump: Important Concepts
• Preload volume overload
• Contractility: ventricles contract during systole
• Afterload pressure overload
• Cardiac output: stroke volume x heart rate
• Blood pressure: cardiac output x systemic

vascular resistance

Examination of the Heart
• The major elements of the cardiac exam include
observation, palpation, and most importantly,
auscultation (percussion is omitted)
• The patient should rest supine with the upper

body elevated 30 to 45 degrees
• Remember assessment of pulse and blood

pressure are important elements of the cardiac
exam
Blood Pressure
• Systolic blood pressure
– Pressure generated by the left ventricle (LV)
during systole, when the LV ejects blood into the
aorta and the arterial tree
o Pressure waves in the arteries create pulses
• Diastolic blood pressure
– Pressure generated by blood remaining in the
arterial tree during diastole, when the ventricles
are relaxed

Beginning the Examination:
The Vital Signs
• First, observe the patient, then begin assessing
the vital signs
– Blood pressure
o Select the proper size cuff
o Position the patient properly
o Make sure there is a brachial pulse
o Apply the cuff correctly
o Assess blood pressure for hypertension
– Heart rate: radial vs. apical
Observation
• Assessment for distention of the right Internal
Jugular vein (IJ) is important because it lies in the in
straight-line communication with the right atrium
• Distention indicating elevation of Central Venous
Pressure (CVP).
• Remember that you can't actually see the IJ vein

• The External Jugular (EJ) runs in an oblique
direction across the sternocleidomastoid and, in
contrast to the IJ, can usually be directly visualized

Jugular Venous Pressure (JVP)
and Pulsations
• Recall that jugular veins reflect right atrial pressure
• Steps for examination
– Raise the head of the bed or examining table to 30°
– Turn the patient’s head gently to the left
– Identify the topmost point of the flickering venous
pulsations
– Place a centimeter ruler upright on the sternal angle
– Place a card or tongue blade horizontally from the top
of the JVP to the ruler, making a right angle
– Measure the distance above the sternal angle in
centimeters: a 3- to 4-centimeter elevation is normal
Observation

Observation

Observation

Palpation
• The palm of your right hand is placed across the patient's
left chest so that it covers the area over the heart. The
heel should rest along the sternal border with the
extended fingers lying below the left nipple
• Focus on several things:

Palpation
• Can you feel a Point of Maximum Impulse (PMI)
• If so, where is it located?
• After identifying the rough position with the palm of your hand,
try to pin down the precise location with the tip of your index
finger
• If the ventricle becomes dilated, the PMI is displaced laterally
• Obesity and COPD may also limit your ability to identify its
precise location

Assessing the Point of Maximal Impulse
(PMI)
• Inspect the left anterior chest for a visible PMI
• Using your finger pads, palpate at the apex for the PMI
• The PMI may be:
– Tapping — normal
– Sustained — suggests LV hypertrophy from
hypertension or aortic stenosis
– Diffuse — suggests a dilated ventricle from
congestive heart failure or cardiomyopathy
• Locate the PMI by interspace and distance in centimeters
from the midsternal line
• Assess location, amplitude, duration, and diameter
Palpating the Chest Wall
• Using the finger pads, palpate for heaves or lifts from
abnormal ventricular movements
• Using the ball of the hand,
palpate for thrills, or
turbulence transmitted to
the chest wall surface by
a damaged heart valve
– Palpate the chest
wall in the aortic,
pulmonic, left
parasternal, and
apical areas
Palpating the Chest Wall
• Palpation of a female patient is best done by placing the
palm of your right hand directly beneath the patient's left
breast
• Make sure that you tell that patient what you are about
to do (and why) before actually performing this
maneuver

Question
When examining a patient for the apical impulse

(PMI), which of the following is LEAST important
to assess?
a. Location
b. Amplitude
c. Rhythm
d. Diameter

Answer
c. Rhythm
• Assess location, amplitude, duration, and

diameter

Assessing the Carotid Pulse
• Keep the patient’s head elevated to 30°
• Place your index and middle fingers on the right then the
left carotid arteries, and palpate the carotid upstroke
• Never palpate right and left carotid arteries
simultaneously
• The upstroke may be:
– Brisk – normal
– Delayed – suggests aortic stenosis
– Bounding – suggests aortic insufficiency
• Listen with the stethoscope for any bruits
Listening to the Heart — Auscultation
• Listen in all 6 listening areas for S1 and S2 using
the diaphragm of the stethoscope
• Then listen at the apex with the bell
• The diaphragm and the bell ...
– The diaphragm is best for detecting high-
pitched sounds like S1, S2, and also S4 and
most murmurs
– The bell is best for detecting low-pitched
sounds like S3 and the rumble of mitral
stenosis
Question
The bell of the stethoscope is most useful for

auscultating:
a. Diastolic murmurs
b. High-pitched heart sounds
c. Low-pitched heart sounds
d. Systolic clicks
e. Systolic murmurs

Answer
c. Low-pitched heart sounds
• The bell is best for detecting low-pitched

sounds like S3 and the rumble of mitral
stenosis

Auscultation
• S1 will be loudest over the left 4th intercostal space
(mitral/tricuspid valve areas)
• S2 along the 2nd R and L intercostal spaces

(aortic/pulomonic valve regions)
• Note that the time between S1 and S2 is shorter then

that between S2 and S1

Auscultation

Auscultation
• In younger patients, you should also be able to detect
physiologic splitting of S2.
• That is, S2 is made up of 2 components, aortic (A2) and

pulmonic (P2) valve closure.
• On inspiration, venous return to the heart is augmented
and pulmonic valve closure is delayed, allowing you to
hear first A2 and then P2.

Auscultation
• On expiration, the two sounds occur closer together and
are detected as a single S2
• Ask the patient to take a deep breath and hold it, giving
you a bit more time to identify this phenomenon.
• The two components of S1 (mitral and tricuspid valve
closure) occur so close together that splitting is not
appreciated.

Auscultation

Physiologic Splitting of S2

Auscultation
• Extra heart sounds
• While present in normal subjects up to the ages of 20-
30, they represent pathology in older patients
• S3 is most commonly associated with left ventricular
failure
• Caused by blood from the left atrium slamming into an
already overfilled ventricle during early diastolic filling

Extra Heart Sounds (S3)

Auscultation
• The S4 is a sound created by blood trying to enter a stiff,
non-compliant left ventricle during atrial contraction
• It's most frequently associated with left ventricular
hypertrophy that is the result of long standing
hypertension
• These sounds are quite soft and referred to as a
summation gallop.

Extra Heart Sounds (S4)

Summation Gallop

Listening for Extra Heart Sounds

Listening for Extra Heart Sounds

Listening for Murmurs
• Murmurs: These are sounds that occur during systole or

diastole as a result of turbulent ‫ هائج‬blood flow.

Most Common Murmurs
Systolic Murmurs
• In the adult population, these generally represent either
• Aortic stenosis or
• Mitral regurgitation

Murmurs of Aortic Stenosis
• Tend to be loudest along the upper sternal borders and
get softer as you move down and out towards the axilla
• Have a growling, harsh quality (i.e. get louder and then
softer)
• Are better heard when the patient sits up and exhales

Murmurs of Aortic Stenosis

Murmurs of Mitral Regurgitation
• Sound the same throughout systole
• Generally do not have the harsh quality associated with

aortic stenosis
• Get louder as you move your stethoscope towards the

axilla.

Murmurs of Mitral Regurgitation

Diastolic Murmurs
• Tend to be softer and therefore much more difficult to
hear then those occurring during systole
• In adults they may represent either
• Aortic regurgitation or
• Mitral stenosis

Diastolic Murmurs/ Aortic regurgitation

Diastolic Murmurs/Mitral stenosis

Describing Heart Murmurs:
Timing and Duration
• Identify and describe any murmurs
• Timing: are the murmurs systolic or diastolic?
– Tip: palpate the carotid upstroke (occurs in
systole) as you listen
– If the murmur coincides with the carotid
upstroke, it is systolic
• Duration
– Early / mid / or late systolic
– Early / mid / or late diastolic
Early Murmurs

Late Murmurs

Shape and Intensity
• Shape Crescendo
– Crescendo, decrescendo,
or both (sometimes called Decrescendo
diamond-shaped)
o Example, crescendo-
decrescendo systolic Both
murmur of aortic
stenosis

Shape and Intensity (cont.)
• Shape
Plateau Machinery
– Plateau ... machinery
o Example, holosystolic
murmur of mitral
regurgitation
• Intensity: grade the murmur
on a scale of 1 to 6
– Grades 4 through 6 must
have accompanying thrill

Shape of Mitral Regurgitation

Aortic Insufficiency

Quality, Pitch, and Location
• Quality
– Apply terms like harsh, musical, soft, blowing,
or rumbling
• Pitch
– Apply terms like high-, medium-, or low-pitched
• Examples
– Harsh 2/6 medium-pitched holosystolic murmur best
heard at the apex describes mitral regurgitation
– Soft, blowing 3/6 decrescendo diastolic murmur best
heard at the lower left sternal border describes aortic
regurgitation
Bad Exam Options When Ausculting Female or
Male Patients

Good Exam Options When Ausculting Female
Patients

Adult Stethoscope

Z-Technique

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Chapter 9

The Cardiovascular System

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Visualize the circulation through the:

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Note the heart chambers and valves and the

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Preload volume overload

• Contractility: ventricles contract during systole

• Afterload pressure overload

• Cardiac output: stroke volume x heart rate

• Blood pressure: cardiac output x systemic

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• The patient should rest supine with the upper

• Remember assessment of pulse and blood

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Remember that you can't actually see the IJ vein

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

When examining a patient for the apical impulse

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Assess location, amplitude, duration, and

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

The bell of the stethoscope is most useful for

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

c. Low-pitched heart sounds

• The bell is best for detecting low-pitched

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• S2 along the 2nd R and L intercostal spaces

• Note that the time between S1 and S2 is shorter then

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• That is, S2 is made up of 2 components, aortic (A2) and

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Murmurs: These are sounds that occur during systole or

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Sound the same throughout systole

• Generally do not have the harsh quality associated with

• Get louder as you move your stethoscope towards the

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins