Download Airgas template - Acupuncture and Massage College

Chapter 8:
The Cardiovascular System
Dr. Felix Hernandez M.D.
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 — 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
• Can you count interspaces?
– identify your own ...
• the midsternal line
• the midclavicular line
• the anterior axillary line
• the midaxillary line
Visualize the Chambers of the Heart and
Important Great Vessels
• Test yourself
• Can you visualize the circulation through:
– the superior and inferior vena cavas
– the right atrium and the right ventricle ventricle
– the pulmonary arteries
– the left atrium and left ventricle
– the aorta and the aortic arch
The Heart as a Pump:
Key Points for Examining the Heart
• Remember the heart chambers and valves and the
forward flow of blood from 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
Blood Pressure
• Systolic Blood Pressure
– Pressure generated by left ventricle (LV) during
systole, when the LV ejects blood into the aorta
and the arterial tree. Pressure waves in the arteries
create pulses
• Diastolic Blood Pressure
– Pressure generated by blood remaining in arterial
tree during diastole, when the ventricles are relaxed
Beginning the Examination:
The Vital Signs
• First Observe The Patient Then … Begin with the vital signs
– Blood Pressure
• Select the proper size cuff
• Position the patient properly
• Make sure there is a brachial pulse
• Apply the cuff correctly!
• Assess blood pressure for hypertension
– Heart Rate: radial vs. apical
Jugular Venous Pressure (JVP)
and Pulsations
• Recall that the 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 - 4 centimeter elevation is normal
Assessing the Carotid Pulse
• Keep the patient’s head elevated to 30°
• Place your index and middle fingers on the right then the
right carotid arteries, and palpate the carotid upstroke
• The upstroke may be:
– Brisk, or normal
– Delayed – suggests aortic stenosis, or
– Bounding – suggests aortic insufficiency
• Listen with the stethoscope for any bruits
Palpating the Chest Wall
• Using the fingerpads, 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
Assessing the PMI,
or point of maximal impulse
• Inspect the left anterior chest for a visible PMI
• Using you fingerpads, palpate at the apex for the PMI
• The PMI may be:
– Tapping, or normal
– Sustained — suggests LV hypertrophy from
hypertension or aortic stenosis, or
– Diffuse — suggests a dilated ventricle from
congestive heart failure or cardiomyopathy
• Locate the PMI by interspace and distance in centimeters
from the midsternal line
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 rumble of mitral stenosis
Describing Heart Murmurs:
Timing and Duration
• Identify and describe any murmurs
• Timing — are they 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
Describing Heart Murmurs:
Shape and Intensity
• Shape
– Crescendo, decrescendo,
or both (sometimes called
diamond-shaped)
• Example, crescendodecrescendo systolic
murmur of aortic stenosis
Crescendo
Decrescendo
Both
Describing Heart Murmurs:
Shape and Intensity (cont.)
• Shape
– Plateau ... machinery
• Example, holosystolic
murmur of mitral
regurgitation
• Intensity — grade the murmur
on a scale of 1 to 6
– grades 4 - 5 - 6/6 must
have accompanying thrill
Plateau Machinery
Describing Heart Murmurs:
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