Download Cardiovascular Objectives

Cardiovascular Objectives
Last semester in the skills session we learned about cardiac auscultation. Today’s class will focus on the vascular exam. In your small
groups, you will have the opportunity to review and practice the vascular examination and cardiac auscultation.
Goal 1
Develop the skills to find and describe vascular abnormalities
Objectives:
a. Know how to measure blood pressure
Blood pressure is usually measured in the patient’s arm. The patient’s arm should be slightly flexed and comfortably supported
on a table, pillow, or your hand. Be sure that the arm is free of clothing. Apply an appropriately sized cuff snugly and securely
because a loose cuff will give an inaccurate diastolic measurement. Center the deflated bladder over the brachial artery, just
medial to the biceps tendon, with the lower edge 2 to 3 cm above the antecubital crease. Place the bell of the stethoscope over the
brachial artery and, pausing for 30 seconds, inflate the cuff until it is 20 to 30 mm Hg above the palpable systolic blood pressure.
The bell of the stethoscope is more effective than the diaphragm in transmitting the low-pitched sound produced by the turbulence
of blood flow in the artery (Korotkoff sounds). Deflate the cuff slowly, listening for the following sounds:


Two consecutive beats indicate the systolic pressure and also the beginning of phase 1 of the Korotkoff sounds.
Occasionally, the Korotkoff sounds will be heard, disappear, and reappear 10 to 15 mm Hg lower (phase 2). The period
of silence is the auscultatory gap.
 Widens  systolic hypertension in elderly (loss of arterial pliability) or drop in diastolic pressure (chronic
severe aortic regurgitation)
 Narrows  pulsus paradoxus with cardiac tamponade or other constrictive cardiac events.
Note the point at which the sounds, that are first crisp (phase 3), become muffled (phase 4). This is the first diastolic
sound, which is considered to be the closes approximation of direct diastolic arterial pressure. it signals imminent
disappearance of the Korotkoff sounds.
Note the point at which the sounds disappear (phase 5). This is the second diastolic sound. Now deflate the cuff
completely.


Repeat the process in the other arm. Readings between the arms may vary by as much as 10 mm Hg and tend to be higher in the
right arm; the higher reading should be accepted as closest to the patient’s blood pressure. The American Heart Association
recommends recording three values for the blood pressure: the systolic and both diastolic measures. If only two values are
recorded, they are the systolic and the second diastolic pressures. The difference between the systolic and diastolic pressures is
the pulse pressure. The expected range is approximately 100 to 140 mm Hg for the systolic pressure and 60 to 90 mm Hg for the
(second) diastolic sounds. The pulse pressure should range from 30 to 40 mm Hg, even to as much as 50 mm Hg.
b.
Know how to numerically rate pulses
The pulses are best palpated over arteries that are close to the surface of the body and that lie over bones. These include the
carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial. The amplitude of the pulse is described on a scale
of 0 to 4:
4
3
2
1
0
c.
Bounding
Full, increased
Expected
Diminished, barely palpable
Absent, not palpable
Know auscultation points for bruits
Auscultate over an artery for a bruit (i.e., a murmur or unexpected sound) if you are following the radiation of murmurs first noted
during the cardiac exam or looking for evidence of local obstruction. These sounds are usually low pitched and relatively hard to
hear. Place the bell of the stethoscope directly over the artery. Sites to auscultate for a bruit are over the temporal, carotid,
subclavian, abdominal aorta, renal, iliac, and femoral arteries. When listening over the carotid vessels, ask the patient to hold a
breath for a few heartbeats so that respiratory sounds will not interfere with auscultation. Carotid artery bruits are best heard at
the anterior margin of the sternocleidomastoid muscle. These may include the following types: transmitted murmurs (e.g., aortic
stenosis, ruptured chordae tendineae of mitral valve, aortic regurgitation), vigorous left ventricular ejection, or obstructive disease
in carotid arteries (e.g., atherosclerotic carotid arteries, fibromuscular hyperplasia, or arteritis).
d.
Know how to measure jugular venous distention
Careful measurement of jugular venous pressure (JVP) is an important and, in some instances, critical portion of the physical
exam. The patient initially is placed in the supine position. This position results in engorgement of the jugular veins. The head
of the bed is raised gradually until the jugular venous pulsations become evident between the angle of the jaw and the clavicle.
Palpating the contralateral carotid pulse will help identify the venous pulsations and distinguish them from the carotid pulsations.
A ruler is placed with its tip at the midaxillary line at the level of the nipple and extended vertically. Another ruler, placed at the
level of the meniscus of the JVP, is extended horizontally to where it intersects the vertical ruler, and the vetical distance above
the level of the heart is noted as the mean jugular venous pressure in centimeters water. A value of less than 9 cm H 2O is the
expected value. The number can be divided by 1.3 to calculate its value in millimeters of mercury.
e.
Know what abnormal venous waveforms mean
The activity of the right side of the heart is transmitted back through the jugular veins as a pulse that has 5 identifiable
components—three peaks and two descending slopes. The a wave, the first and most prominent component, is the result of a
brief backflow of blood to the vena cava during right atrial contraction. The c wave is a transmitted impulse from the vigorous
backward push produced by closure of the tricuspid valve during ventricular systole. The v wave is caused by the increasing
volume and concomitant increasing pressure in the right atrium. It occurs a split moment after the c wave, late in ventricular
systole. The x slope is caused by passive atrial filling, whereas the y slope reflects the open tricuspid valve and rapid filling of the
ventricle. In JVP disorders, venous waveforms are abnormal:




f.
Tricuspid regurgitation: the v wave is much more prominent, occurs earlier, and merges with the c wave.
Atrial fibrillation: the a wave is absent and there are only two venous pulsations for each arterial pulsation; time
between v waves is variable.
Cardiac tamponade: the y slope is abolished; the JVP is markedly elevated and fails to fall with inspiration.
Constrictive pericarditis: JVP is elevated but there is a prominent y slope (Y-descent).
Know how to numerically rate edema
The severity of edema may be characterized by grading 1+ through 4+. If edema is unilateral, suspect occlusion of a major vein;
if edema is bilateral, consider congestive heart failure. If edema occurs without pitting, suspect arterial disease and occlusion.
Any concomitant pitting can be mild or severe:
1+
2+
3+
4+
Slight pitting, no visible distortion, disappears rapidly
Somewhat deeper pit, no visible distortion, disappears in 10 to 15 seconds
Noticeably deep pit, may last more than a minute; the dependent extremity looks fuller and swollen
Very deep pit, lasts as long as 2-5 minutes; the dependent extremity is grossly distorted
Goal 2
Develop the ability to perform a normal heart exam
Objectives:
a. Be able to palpate precordium and describe PMI
To palpate the precordium, use the proximal halves of the four fingers held gently together or the whole hand. Touch gently and
let the cardiac movements rise to your hand because sensation will decrease as you increase pressure. One suggested sequence is
to begin at the apex, move to the left sternal border, and then move to the base, going down to the right sternal border and into the
epigastrium or axillae if circumstances dictate. The point at which the apical impulse is most readily seen or felt should be
described as the point of maximal impulse (PMI).
b.
Know ausculatory points for cardiac exam
There are five traditionally designated auscultatory areas:





Aortic valve: 2nd right intercostal space at right sternal border
Pulmonic valve: 2nd left intercostal space at left sternal border
Second pulmonic area: 3rd left intercostal space at left sternal border
Tricuspid valve: 4th left intercostal space along lower left sternal border
Mitral valve: 5th left intercostal space at midclavicular line at apex of the heart
c.
Be able to describe normal heart sounds
Assess the rate and rhythm of the heart. S1 coincides with the rise of the carotid pulse; note any splitting of S1. Concentrate on
systole; S1 marks the beginning of systole. Concentrate on diastole which is longer than systole; S1 immediately follows diastole.
Listen for S2 to become two components (S2 splitting) during inspiration. Heart sounds are characterized by pitch, intensity,
duration, and timing in the cardiac cycle. Heart sounds are relatively low in pitch. There are four basic heart sounds: S1, S2, S3,
and S4. Of these, S1 and S2 (closure of AV valves) are the most distinct heart sounds and should be characterized separately
because variations can offer important clues to cardiac function. S3 (Ken-tuc-ky) and S4 (Tenn-es-see) may or may not be
present; their absence is not an unusual finding, but their presence does not necessarily indicate a pathologic condition. Thus S3
and S4 must be evaluated in relation to other sounds and events in the cardiac cycle.
Goal 3
Develop the ability to describe abnormal heart sounds
Objectives:
a. Learn to describe changes in the timing of heart sounds and be able to relate them to possible cardiopulmonary pathology
(physiologic splitting vs. fixed split, widened split, reverse/paradoxical split)
Fixed split: Splitting is said to be fixed when it is unaffected by respiration (nl: splitting is greatest at peak of inspiration and
tends to eliminate in expiration). This ocurs with delayed closure of the pulmonic valve when output of the right ventricle is
greater than that of the left (i.e., large ASD, VSD with L-to-R shunt, or right ventricular failure).
Widened split: The split becomes wider when there is delayed activation of contraction or emptying of the right ventricle
resulting in delay in pulmonic closure. This occurs in right bundle branch block, which splits both S1 and S2. Wide splitting of
S2 also occurs when stenosis delays closure of the pulmonic valve, when pulmonary HTN delays ventricular emptying, or when
mitral regurgitation induces early closure of the aortic valve. The split becomes narrower and is even eliminated or paradoxic
when closure of the aortic valve is delayed, such as in left bundle branch block.
Reverse/Paradoxical split: Paradoxic splitting occurs when closure of the aortic valve is delayed (such as in left bundle branch
block) so that P2 occurs first, followed by A2. In this case, the intervale between P2 and A1 is heard during expiration and
disappears during inspiration.
b.
Be able to listen for clicks, S3, S4
During diastole the ventricles fill in two steps: early passive flow of blood from atria is followed by more vigorous atrial ejection.
The passive phase occurs early in diastole, distending the ventricular walls and causing vibration, resulting in S3—a quiet, low
piched sound that is often difficult to hear. In the second phase of ventricular filling, vibration in the valves, paillae, and
ventricular walls produces S4. Because it occurs so late in diastole, S4 may be confused with a split S1. S3 and S4 should be
quiet and difficult to hear.
c.

S3: When S3 becomes intense and easy to hear, the resultatnt sequence of sounds simulates a gallop—protodiastolic
gallop. S3 may be louder if filling pressure increases or if ventricular compliance decreases. S3 is best heard in the left
recumbent position.

S4: S4 may also become more intense, producing a presystolic gallop. S4 is most commonly heard in older patients but
may be heard at any age when there is increased resistance to filling due to loss of compliance of ventricular walls (e.g.,
HTN and CAD) or increased stroke volume of high-output states (e.g., profound anemia, pregnancy, thyrotoxicosis). A
large S4 is always pathologic.

Clicks: The cardiac valves generally open noiselessly unless thickened, roughened, or otherwise altered as a result of
disease. Valvular stenosis may produce an opening snap (mitral valve), ejection clicks (semilunar valves), or mid-to-late
nonejection systolic clicks (mitral prolapse). The pulmonary ejection click is best heard on expiration, and seldom heard
on inspiration; aortic ejection clicks are less sharp, are less involved with S1, and may be heard as distant as the anterior
axillary line.
Know how to describe cardiac murmurs-timing, loudness, pitch, radiation (see Table 13-4, p. 442)
Timing and Duration: early systolic, midsystolic, late systolic, early diastolic, middiastolic, late diastolic (presystolic),
holosystolic (pansystolic), holodiastolic (pandiastolic), continuous
Pitch: High, medium, low; Depends on pressure and rate of blood flow – low pitch is heard best with bell.
Radiation: Anatomic landmarks (e.g., to axilla or carotid arteries); Site farthest from location of greatest intensity at which sound
is still heard – sound usually transmitted in direction of blood flow.
Intensity (Loudness):
Grade I
Grade II
Grade III
Grade IV
Grade V
Grade VI
d.
Barely audible in quiet room
Quiet but clearly audible
Moderately loud
Loud, associated with thrill
Very loud, thrill easily palpable
Very loud, audible with stethoscope not in contact with chest, thrill palpable and visible
Know maneuvers to help elicit types of murmurs
Right-sided chambers: inspiration increases intensity
Hypertrophic cardiomyopathy: Valsalva, squatting to standing (rapidly for 30 seconds) increases intensity
Mitral regurgitation: handgrip increases intensity
Ventricular septal defect: transient arterial occlusion (using sphygmomanometer) increrases intensity
Aortic stenosis: no maneuver distinguishes this murmur; the diagnosis can be made by exclusion
e.
Be able to describe findings typical of aortic stenosis, mitral regurgitation, aortic insufficiency and mitral stenosis
Aortic stenosis: Calcification of aortic valve restricts outward flow; forceful ejection from ventricle into systemic circulation.
Heard over aortic area; ejection sound at 2nd right intercostals border. Midsystolic (ejection) murmur, medium pitch, coarse,
diamond shaped, crescendo-decrescendo; radiates down left sternal border (sometimes to apex) and to carotid with palpable thrill;
S1 often heard best at apex, disappearing when stonsis is severe, often followed by ejection click; S2 soft or absent and may not
be split; S4 palpable; ejection sound muted in calcified valves; the more severe the stenosis, the later the peak of the murmur is
systole. Apical thrust shifts down and left and is prolonged if left ventricular hypertrophy is also present.
Mitral regurgitation: Mitral valve incompetence allows backflow from ventricle to atrium. Heard best at apex; loudest there,
transmitted into left axilla. Holosystolic, plateau-shaped intensity, high pitch, harsh blowing quality, often quite loud and may
obliterate S2; radiates from apex to base or to left axilla; thrill may be palpable at apex during systole; S4 intensity diminished S2
more intese with P2 often accented; S3 often present; S3-S4 gallop common in late disease. If mild, late systolic murmur
crescendos; if severe, early systolic intensity decrescendos; apical thrust more to left and down in ventricular hypertrophy.
Aortic insufficiency: Aortic valve incompetence allows backflow from aorta to ventricle. Heard with diaphragm, patient sitting
and leaning forward; ejection click heard in 2 nd intercostal space. Early diastolic, high pitch, blowing, often with diamond-shaped
midsystolic murmur, sounds often not prominent; duration varies with blood pressure; low-pitched, rumbling murmur at apex
common (Austin Flint); early ejection click sometimes present; S1 soft; S2 split may have tambourlike quality; M1 and A2 often
intensified, S3-S4 gallop common. In left ventricular hypertrophy, prominent prolonged apical impulse down and to left. Pulse
pressure wide; water-hammer or bisferiens pulse common in carotid, brachial, and femoral arteries.
Mitral stenosis: Narrowed mitral valve restricts outward flow; forceful ejection into ventricle. Heard with bell at apex, patient in
left recumbent position. Low-frequency diastolic rumble, more intese in early and late diastole, does not radiate; systole usually
quiet; palpable thrill at apex in late diastole common; S1 increased and often palpable at left sternal border; S2 split often with
accented P2; opening snap follows P2 closely. Visible lift in right parasternal area if right ventricle hypertrophied. Arterial pulse
amplitude decreased.
f.
Be able to check for heaves/lifts and thrills
The apical impulse is usually gentle and brief, not lasting as long as systole. If it is more vigorous than expected, characterize it
as a heave or lift. In many adults, the apical impulse cannot be felt due to the thickness of the chest. A thrill is a fine, palpable,
rushing vibration, a palpable murmur, often, but not always, over the base of the heart in the area of the right or left 2 nd intercostal
space. It generally indicates a disruption of the expected blood flow related to some defect in the closure of one of the semilunar
valves (generally aortic or pulmonic stenosis), pulmonary HTN, or ASD.
Cardiovascular Vocabulary
Tachycardia- abnormally rapid heart rate. Used to be define as a resting heart rate> 100, but some experts have decreased that to 90
Bradycardia- abnormally slow heart rate < 60,br> Orthopnea- difficult breathing except in the upright position
Cardiomegaly- hypertrophy of the heart
Diaphoresis- perspiration
Cyanosis- bluish appearance of the skin and mucus membranes due to excessive concentration of reduced hemoglobin in the blood
Functional murmur- murmur generated in a structurally normal heart (also called “innocent murmur”)
Ejection murmur- systolic murmurs heard predominantly in midsystole when ejection volume and velocity of blood flow are at their
maximum
Roth spots- round or oval spots sometimes seen on the retina in subacute bacterial endocarditis
Oslers nodes- small, raised, tender, swollen areas, bluish or pink or red, occurring commonly in the pads of the fingers or toes, in the
thenar or hypothenar eminences, or the soles of the feet; they are practically pathognomonic of subacute bacterial endocarditis
Janeway lesions- a small erythematous or hemorrhagic lesion, usually on the palms or soles , in bacterial endocarditis