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Chapter 14
Heart
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First things first
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Heart and blood flow
Cardiac circulation
Left and Right sided failure – symptoms
Angina and MI
Emergency treatment: MONA (last slide)
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Heart
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The main function of the heart is to circulate
blood through the body and lungs.
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Two separate circulations
Located in the mediastinum
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Figure 14-02. Heart within the Pericardium.
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Structure (Cont.)
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Chambers
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Two upper chambers are the right and left atria
• Thin-walled chambers that act primarily as reservoirs for
blood returning to the heart from the veins throughout the
body
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Two bottom chambers are the right and left
ventricles
• Thick-walled chambers that pump blood to the lungs and
throughout the body
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Structure (Cont.)
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Chambers
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Septum: divides right and left heart
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Structure (Cont.)
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Valves: permit the flow of blood in only one
direction
Atrioventricular
• Tricuspid valve, which has three cusps (or leaflets),
separates the right atrium from the right ventricle.
• Mitral valve, which has two cusps, separates the left
atrium from the left ventricle.
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Semilunar
• Two semilunar valves, each has three cusps.
• Pulmonic valve separates the right ventricle from the
pulmonary artery.
• Aortic valve lies between the left ventricle and the aorta.
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Cardiac Cycle
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To help ensure proper circulation, the heart
contracts and relaxes rhythmically, creating a
two-phase cardiac cycle.
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Systole
Diastole
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Figure 14-06. Blood Flow through the Heart. A, Systole. B, Diastole. (From Canobbio, 1990.)
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Systole
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Ventricles contract.
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Mitral and tricuspid valves close
(first heart sound).
Pressure continues to rise.
Aortic and pulmonic valves open.
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Blood is ejected from the left ventricle into the aorta and from
the right ventricle into the pulmonary artery.
Blood ejected into arteries.
Pressure falls.
Aortic and pulmonic valves close
(second heart sound).
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Diastole
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Mitral and tricuspid valves open.
Blood moves from atria to ventricles
(third heart sound).
Ventricles dilate, an energy-requiring effort
that draws blood into the ventricles as the
atria contract, thereby moving blood from the
atria to the ventricles. (Starling’s Law)
Atria contract as ventricles almost filled.
Causes complete emptying of atria
(fourth heart sound).
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Electrical Activity
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Intrinsic electrical conduction system enables
the heart to contract w/in itself (Automaticity)
Coordinates the sequence of muscular
contractions taking place during the cardiac
cycle
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Sinoatrial node (SA node) (60-100 spm)
Atrioventricular node (AV node) (40-60 spm)
Bundle of His (approx 30-40 spm)
 Purkinje fibers
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Electrical Activity (Cont.)
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An electrocardiogram (ECG) is a graphic
recording of electrical activity during the
cardiac cycle.
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Figure 14-09. Usual Electrocardiogram Waveform. (From Berne and Levy, 1996.)
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Electrocardiogram (ECG)
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ECG waves
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P wave: the spread of a stimulus through the atria
PR interval: the time from initial stimulation of the atria to
initial stimulation of the ventricles
QRS complex: the spread of a stimulus through the
ventricles
ST segment and T wave: the return of stimulated ventricular
muscle to a resting state
U wave: a small deflection sometimes seen just after the T
wave
Q-T interval: the time elapsed from the onset of ventricular
depolarization until the completion of ventricular
repolarization
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Older Adults
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Heart size may decrease.
Left ventricular wall thickens.
Valves fibrose and calcify.
Heart rate slows.
Stroke volume decreases.
Cardiac output during exercise declines by
30% to 40%.
(Atrial Fib and Cardiac Output)
Endocardium thickens.
Myocardium becomes less elastic.
Electrical irritability may be enhanced.
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Older Adults (Cont.)
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ECG tracing changes
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First-degree atrioventricular block
Bundle branch blocks
ST wave abnormalities
Premature systole (atrial and ventricular)
Left ventricular hypertrophy
Atrial fibrillation
TAKE HOME MESSAGE: THINGS CHANGE IN
THE ADULT HEART
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Review of Related History
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History of Present Illness
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Chest pain
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Onset and duration
Character
Location
Severity
Associated symptoms
Treatment
Medications: prophylactic penicillin
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History of Present Illness (Cont.)
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Fatigue
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Unusual or persistent
Inability to keep up with peers
Associated symptoms
Medications (e.g Beta blockers)
Cough
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Onset and duration
Character
Medications: (e.g. ACE inhibitors)
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History of Present Illness (Cont.)
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Difficulty breathing (dyspnea, orthopnea)
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Aggravated by exertion
On level ground, climbing stairs
Worsening or remaining stable
Lying down or eased by resting on pillows
• (How many? Or sleep in a recliner?)
Paroxysmal nocturnal dyspnea
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History of Present Illness (Cont.)
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Loss of consciousness (transient syncope)
associated with:
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Palpitation
Dysrhythmia
Unusual exertion
Sudden turning of neck (carotid sinus effect)
Looking upward (vertebral artery occlusion)
Change in posture
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Family History
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Diabetes
Heart disease
Dyslipidemia
Hypertension
Congenital heart defects
Family members with cardiac risk factors
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Personal and Social History
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Employment
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Physical demands
Environmental hazards
Tobacco use
Nutritional status
Personality assessment
Relaxation activities
Use of alcohol and/or drugs
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Older Adults
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Common symptoms of cardiovascular
disorder
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Confusion and syncope
Palpitations
Coughs and wheezes
Hemoptysis
Shortness of breath
Chest pain and tightness
Incontinence, impotence, and heat intolerance
Fatigue
Leg edema
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Examination and Findings
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The examination of the heart includes the
following:
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Auscultate
Palpate artery sites
Inspect Jugular distention
Rarely Percussing the chest
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Equipment
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Stethoscope with bell and diaphragm
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Palpation
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Pulse sites
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Palpation (Cont.)
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Apical impulse
Carotid artery palpation
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Auscultation
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There are five traditionally designated
auscultatory areas, located as follows:
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Aortic valve area
• Second right intercostal space at the right sternal border
Pulmonic valve area
• Second left intercostal space at the left sternal border
Second pulmonic area
• Third left intercostal space at the left sternal border
(ERBS Point)
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Auscultation (Cont.)
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Five auscultatory areas
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Tricuspid area
• Fourth left intercostal space along the lower left sternal
border
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Mitral (or apical) area
• Apex of the heart in the fifth left intercostal space at the
midclavicular line
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Auscultation (Cont.)
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Assess overall rate and rhythm
Pathology such as . . . .
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Heart Sounds
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Basic heart sounds
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S1 or S2 most distinct
Extra heart sounds
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Gallops
Murmurs
Mitral snaps
Ejection clicks
Friction rubs
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Rhythm Disturbance
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Determine the steadiness of the heart rhythm,
which should be regular.
If it is irregular, determine whether there is a
consistent pattern.
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Irregular but occurring in a repeated pattern may
indicate sinus dysrhythmia, a cyclic variation of the
heart rate
Patternless, unpredictable, irregular rhythm may
indicate heart disease or conduction system
impairment
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Older Adults
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Slow down pace of examination; cardiac
response may be slowed by demands of
positional changes.
Heart rate is variable:
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Slower if increased vagal tone
Range from low 40s to 100+ beats per minute NO
– WE WILL DISCUSS THIS
Ectopic beats common
Apical impulse is harder to find with increased
anteroposterior chest diameter.
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Older Adults (Cont.)
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Diaphragm is raised and heart is transverse
in obese adults.
Exercise may delay age-related changes.
Physiologic murmurs are caused by:
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Aortic lengthening
Sclerotic changes
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Abnormalities
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Heart Murmurs
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Causes
What the sound like
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Cardiac Disorders
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Bacterial endocarditis
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Bacterial infection of the endothelial layer of the
heart and valves
Congestive heart failure
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Heart fails to propel blood forward with its usual
force, resulting in congestion in the pulmonary or
systemic circulation
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Cardiac Disorders (Cont.)
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Cardiac tamponade
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Excessive accumulation of effused fluids or blood
between the pericardium
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Figure 14-23. Hemopericardium and Cardiac Tamponade. (Modified from Canobbio, 1990.)
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Cardiac Disorders (Cont.)
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Pericarditis
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Sudden inflammation of the pericardium
Cor pulmonale
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Enlargement of the right ventricle secondary to
pulmonary malfunction
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Cardiac Disorders (Cont.)
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Myocardial infarction
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Ischemic myocardial necrosis caused by abrupt
decrease in coronary blood flow to a segment of
the myocardium
Myocarditis
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Focal or diffuse inflammation of the myocardium
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Abnormalities in Heart Rates and
Rhythms
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Conduction
disturbances
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Atrial flutter
Sinus bradycardia
Atrial fibrillation
Heart block
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Atrial tachycardia
Ventricular
tachycardia
Ventricular fibrillation
Sick sinus syndrome
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Arrhythmias caused
by a malfunction of
the sinus node
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Older Adults
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Atherosclerotic heart disease
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Mitral insufficiency/Regurgitation
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Caused by deposition of cholesterol, other lipids,
and by a complex inflammatory process
Abnormal leaking of blood through the mitral
valve, from left ventricle into left atrium
Angina
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Pain caused by myocardial ischemia
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Older Adults (Cont.)
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Senile cardiac amyloidosis
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Amyloid, fibrillary protein produced by chronic
inflammation or neoplastic disease, deposition in
the heart
Aortic sclerosis
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Thickening and calcification of aortic valves
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Selected Medications
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Beta blockers (e.g. Metoprolol)
ACEIs (e.g. Lisinopril)
ARBs (e.g. Valsartan)
Calcium Channel Blockers (e.g. Nifedipine)
Diuretics (e.g. Furosemide)
Anticoagulants (e.g. Warfarin)
ASA
Nitrates (e.g. Nitroglycerine)
MONA
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