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1. CARDIOVASCULAR SYSTEM PCD 3/16/2023 1

2. APPROCH TO CARDIOVASCULAR EXAMINATION Objectives To explain symptoms of cardiac disease To learn a step-wise approach in cardiovascular examination To appreciate the normal and abnormal cardiac findings To interpret cardiac findings 3/16/2023 2

3. Diseases of the cardiovascular system are common at any level of medical practice. Diagnosis of diseases related to the CVS requires thorough history taking and meticulous physical examination. Step-wise approach with proper and repeated examination of patients with cardiovascular disease will enable a student to a precision in diagnosis 3/16/2023 3 Introduction

4. Symptoms of Heart Disease Dyspnea : This is a state of shortness of breath on exertion. But, it may occur at rest as the heart failure progresses. The degree of dyspnea is graded based on the New York Heart Association Class (NYHAC): 3/16/2023 4 History

5. Class I: - No limitation of physical activity - No symptoms with ordinary exertion Class II: - Slight limitation of physical activity - Ordinary activity causes symptoms Class III: - Marked limitation of physical activity - Less than ordinary activity causes symptoms - Asymptomatic at rest Class IV: - Inability to carry out any physical activity without discomfort - Symptoms at rest. 3/16/2023 5 New York Heart Association(NYHA) Functional Classification

6. Paroxysmal Nocturnal Dyspnea (PND): Is shortness of breath that occurs during sleep. Orthopnea : Shortness of breath that occurs during recumbent position. Pain : Angina pectoris is a cardiac origin pain. It arises in the precordial area usually on the retrosternal region and radiates to the left neck, shoulder and left upper arm. It has piercing, or squeezing character which is aggravated by exertion and relieved by rest. 3/16/2023 6

7. Body swelling: Usually which starts from the leg Palpitation: Is subjective unpleasant perception of one’s own heart beat. Cough: Which usually occurs at night (nocturnal) Syncope: Sudden episode of fainting related to hemodynamic derangement. 3/16/2023 7

8. Symptoms of Arterial occlusion: Acute : pain, loss of function, altered cutaneous sensation, gangrene Chronic : Intermittent claudication (pain around calf muscle on walking) which gets relieved with rest Symptoms of Venous insufficiency: Swelling and pain of the affected limb 3/16/2023 8 Symptoms of Peripheral Vascular Disease

9. Equipment Needed Stethoscope A Blood Pressure apparatus A Moveable Light Source or pen light General Considerations The patient must be properly undressed above the waist. The examination room must be quiet to perform adequate auscultation 3/16/2023 9 Physical Examination

10. Observe the patient for general signs of cardiovascular disease Breathing pattern Cyanosis, Finger clubbing, Edema 3/16/2023 10

11. Includes: Arterial examination Venous examination particularly the JVP Precordial examination 3/16/2023 11 Examination of the CVS

12. Components of arterial examination include Rate Rhythm Character Volume (amplitude) Radio-femoral delay Major Arteries: Radial, Brachial, Carotid, Femoral, Popliteal , Posterior Tibial , Dorsalis pedis . All arteries should be palpated symmetrically at the same time except carotid arteries, as this could cut off the blood supply to the brain and cause syncope. 3/16/2023 12 Arterial Pulses

13. Rate and Rhythm: The radial artery is preferred Compress the radial artery with your index and middle fingers Note whether the pulse is regular or irregular. Count the pulse for one full minute. Record the rate and rhythm. Pulse classification in adults 1. Based on the rate Normal: 60 - 100 beats / min Bradycardia: < 60 beats / min Tachycardia: > 100 beats / min 2. Based on rhythm Regular Regularly irregular; e.g. 2nd degree heart block Irregularly irregular: e.g. atrial fibrillation 3/16/2023 13

14. Character and Volume: best checked on carotid arteries 1. Observe for carotid pulsations. 2. Place fingers behind the patient's neck and compress the carotid on one side 3. Assess the following: The amplitude of the pulse. The contour of the pulse wave. Variations in amplitude from beat to beat or with respiration. 4. Repeat on the opposite side 3/16/2023 14

15. 3/16/2023 15

16. Normal Hypokinetic (small volume): found in low output states like heart failure, shock, mitral stenosis etc. Parvus et tardus ( Small Volume And Slow Rising pulse): found in aortic stenosis Bisferiens : a collapsing and slow rising pulse which occurs in mixed aortic disease (AS and AR ) Pulsus alternans : alternating strong and week pulses - hypertrophic cardiomyopathy Pulsus Paradoxus : pulse weakens in inspiration, indicates tamponade or constrictive pericarditis 3/16/2023 16

17. Collapsing (rapid up and rapid down) : Water hammer pulse o strong radial pulse that taps hand up on lifting the arm o indicates wide pulse pressure of aortic regurgitation (also AV fistula or hyperdynamic circulation) Bounding pulse o CO2 retention o Liver failure o Sepsis Radio-femoral delay - suggests coarctation or dissection of aorta 3/16/2023 17

18. The peripheral arteries are: the carotids, the brachial, the radial, the popliteal , dorsalispedis and posterior tibial arteries. Palpate these arteries symmetrically and orderly to assess: Adequacy of the peripheral circulation: by assessing the pulse volume. Symmetry of the arterial pulses. A unilateral decrease of amplitude can be due to obstruction or atherosclerosis. Thickening of the peripheral arteries: due to atherosclerosis the arterial wall may be thickened and the artery becomes palpable. Check for radiofemoral delay. Normally the radial and femoral pulses are simultaneous. Delay of the femoral pulse compared to radial pulse is a sign of aortic coarctation . 3/16/2023 18 Examination of the peripheral arteries

19. Auscultation for Bruits It is often checked in old aged patients. indicates carotid artery stenosis or atherosclerosis of the carotid artery. N.B Don’t be confused by heart sounds or murmurs transmitted from the chest. 3/16/2023 19

20. Jugular Venous Pressure (JVP): is a reflection of the right atrial pressure and it is the most important part of venous system examination Closely parallels pressure in the right atrium, or central venous pressure, related primarily to volume in the venous system. is best assessed from pulsations in the right internal jugular vein, which is directly in line with the superior vena cava and right atrium. 3/16/2023 20 Venous system

21. Steps for Measuring the Jugular Venous Pressure 3/16/2023 21

22. 3/16/2023 22 Interpretation: Normal - is less than or equal to 4 cm of water Elevated - if greater than 4 cm above the sternal angle. This indicates raised right atrial pressure which is most often found in right ventricular failure (dysfunction).

23. 3/16/2023 23 Jugular venous pulsations vs carotid pulsations

24. The precordium is the anterior chest overlying the heart. Precordial examination=cardiac examination Consists of: Inspection Palpation Auscultation Percussion is generally not useful in precordial exam unless indicated. Adequate exposure and light are mandatory The Precordium examination 3/16/2023 24

25. Precordial bulge which may indicate long standing cardiac diseases Precordial movement ( activity ):- -Multiple pulsations( active ):- e.g. multivalvular lesions - Quiet : - e.g. Pericardial effusion Apical beat : - which is the most laterally and downward(inferior) positioned impulse. Any collateral veins-SVC obstruction Inspection 3/16/2023 25

26. PMI( Point of maximal impulse), is an area where the strongest cardiac impulse is felt. Normal location is at the fifth intercostal space in the left mid- clavicular line Heave : sustained systolic lift that results from ventricular hypertrophy. sustained apical heave  LVH Parasternal heave  RVH Thrills : palpable, low frequency vibrations associated with heart murmurs Palpation 3/16/2023 26

27. Apex = mitral valve area, left ventricle Left sternal border = right ventricular area Tricuspid area = LLSB (4 th left interspace just lateral to the sternum) Pulmonic area : 2 nd interspace just lateral to the left sternal border. Aortic area : 2 nd interspace just to the right of the sternum. AREAS OF PALPATION 3/16/2023 27

28. Location : normal- 4 th /5 th interspace along the left MCL or 7-9 cm to the left of the midline. If displaced  shifted apex  cardiac enlargement . Diameter/size : localized- <2.5 cm &/or limited to a single interspace . Diffuse : >2.5cm &/or felt in more than 1 interspace . Amplitude and duration: Tapping : small and brisk MS Hyperkinetic : vigorous but brisk. Sustained : with heave. Characterization of the Apical Impulse 3/16/2023 28

29. Palpation at apical impulse 3/16/2023 29

30. Use the ulnar side of the palm. Apical area and Left parasternal area Palpation heave 3/16/2023 30

31. Palpate over the valve areas with the ball of the palm. Mitral, tricuspid, pulmonic , and aortic areas. Timing: systolic or diastolic determined by simultaneous palpation of the carotid artery . Thrill coincident with carotid pulsation is systolic ; otherwise it’s diastolic. Palpation thrills 3/16/2023 31

32. Has little significance in precordial examination To estimate cardiac size when the apical impulse isn’t palpable. It is done when one suspects dextrocardia or significant mediastinal shift Starting well to the left on the chest, percuss from resonance toward cardiac dullness in the 3rd, 4th, 5th, and possibly 6th interspaces Percussion 3/16/2023 32

33. The auscultatory areas: The aortic area The pulmonic area The third interspace to the left of the sternum ( Erb’s point) The tricuspid area The mitral area Auscultation 3/16/2023 33

34. Use both the diaphragm and the bell. The diaphragm: The diaphragm is better for picking up the relatively high pitched sounds of S1 and S2, the murmurs of aortic and mitral regurgitation, and pericardial friction rubs. The bell . The bell is more sensitive to the low-pitched sounds of S3 and S4 and the murmur of mitral stenosis . The stethoscope 3/16/2023 34

35. Maneuvers used to accentuate cardiac auscultation Have the patient roll on their left lateral side and auscultate at the apex. This position accentuates S3 and mitral murmurs(MS ). Have the patient sit up and lean forward . This position enhances diastolic murmur of aortic regurgitation , and pericardial friction rub . Ask the patient to hold on breathing on inspiration which makes sounds arising from the right side of the heart louder, and if the patient holds on expiration sound originating from the left side of the heart are exaggerated. 3/16/2023 35

36. 3/16/2023 36

37. S1 and S2: the first sounds to focus on. S1: due to closure of the AV valves S2: caused by closure of semilunar valves. - A2 the aortic component and - P2 the pulmonic component. Additional heart sounds: S3 and S4 are both diastolic sounds. The presence of an additional HS gives a gallop rhythm. Murmurs : sounds due to turbulent blood flow across valves . Auscultatory sounds 3/16/2023 37

38. Both heart sounds heard in all auscultatory areas  S1 and S2 are well heard. S1 loud at mitral area (ex. MS)  Loud S1 S1 decreased in intensity  muffled P2 louder than A2  Accentuated P2 A2 louder than P2  accentuated A2 Cont … 3/16/2023 38

39. S1 is loud in o mitral stenosis o tachycardia o hyperdynamic circulation like e.g. anemia • S1 is soft ( Muffled )in :- o mitral regurgitation o bradycardia and LVF • A2 is loud in systemic hypertension • A2 is soft in aortic stenosis • P2 is loud in pulmonary hypertension • P2 is soft in pulmonary stenosis Cont … 3/16/2023 39

40. Murmur is abnormal heart sound due to turbulence of blood flow. It may be innocent (Physiologic) e.g. hyperdynamic states like anemia, pregnancy etc. or pathologic e.g. valvular lesions Characterization of Murmur Timing: systole, diastole, continuous Point of maximum intensity Direction of selective propagation (radiation) The character and quality of the murmur Intensity (grading) 3/16/2023 40 Murmur

41. A) Timing : systolic or diastolic. Palpate the carotid artery to time a murmur or any added sound. Systolic murmurs: may be Pansystolic : starts with S1 and stops at S2, without a gap between murmur and heart. S1 is muffled. Pathological EX. MR Midsystolic : begins after S1 and stops before S2. usually flow murmurs. 3/16/2023 41

42. Diastolic murmurs: early diastolic murmur starts right after S2, without a discernible gap, and then usually fades before S1. ex AR A mid diastolic murmur starts a short time after S2. It may fade away, or merge into a late diastolic murmur. EX MS A late diastolic ( presystolic ) murmur starts late in diastole and typically continues up to s1 Continuous murmurs have both systolic and diastolic component 3/16/2023 42

43. B) Location : is the area of maximal intensity of the murmur. C) Radiation : the direction to which the murmur is transmitted. Mitral systolic murmurs radiate to the axilla ( MR ) Tricuspid murmurs radiate to the epigastrium ( TR ) Aortic murmurs radiate to the neck/carotid ( AS ). Diastolic murmurs don’t radiate. D) Intensity . This is usually graded on a 6-point scale and expressed as a fraction 3/16/2023 43

44. Grade 1 Very faint, heard only after listener has “tuned in”; may not be heard in all positions(1/6) Grade 2 Quiet , but heard immediately after placing the stethoscope on the chest(2/6) Grade 3 Moderately loud(3/6) Grade 4 Loud, with palpable thrill(4/6) Grade 5 Very loud, with thrill. Can be heard when the stethoscope is partly off the chest Grade 6 Very loud, with thrill. May be heard with stethoscope entirely off the chest(6/6) Grading of murmurs 3/16/2023 44

45. Grade Volume Thrill 1/6 Very faint, only heard with optimal conditions No 2/6 Loud enough to be obvious No 3/6 Louder than grade 2 No 4/6 Louder than grade 3 Yes 5/6 Heard with the stethoscope partially off the chest Yes 6/6 Heard with the stethoscope completely off the chest Yes Murmur Grading 3/16/2023 45