Chapter 9: The Cardiovascular System

Heaves

A ___ is a more vigorous movement; sustained forceful thrusting of the ventricles during systole.

Lifts

A ____ is a slight movement when the heart's pumping ability may be forceful

S4 (atrial sound or atrial gallop)

A _____ occurs just before S1; it is dull, low in pitch, and heard better with the bell; it is occasionally normal, especially in trained athletes and older age groups. More commonly it is due to increased resistance to ventricular filling following atrial contraction. This increased resistance is related to decreased compliance of the ventricular myocardium.

Left-sided S4

A _______ is heard best at the apex of the left lateral position; it may sound like "Tennessee"; causes include: hypertensive heart disease, myocardial ischemia, aortic stenosis, and cardiomyopathy

Right-sided S3

A _______ is usually heard along the lower left sternal border or below the xiphoid with the patient supine, and is louder on inspiration

Left-sided S3

A __________ is heard typically at the apex in the left lateral decubitus position

Venous Hum

A continuous murmur; A benign sound produced by turbulence of blood in the jugular veins; without a silent interval loudest in diastole; located above the medial third of the clavicles especially on the right; radiates to 1st and 2nd interspaces, intensity is soft to moderate but can be obliterated by pressure on the jugular veins; quality is humming/roaring; pitch is low heard better with the bell

Patent Ductus Arteriosus

A continuous murmur; A congenital abnormality in which an *open channel* persists between the aorta and pulmonary artery; silent interval late in diastole, loudest in systole, obscures S2 and fades in diastole; located in left 2nd interspace; radiates to left clavicle; intensity is usually loud sometimes with a thrill; quality is harsh; pitch is medium

Pericardial Friction Rub

A continuous murmur; Is produced by inflammation of the *pericardial sac;* may have three short components: atrial and ventricular systole and ventricular diastole - these make diagnosis easy; location is variable usually heard best in 3rd interspace to the left of the sternum; little radiation; variable intensity but may increase when the patient leans forward, exhales, and holds breath; quality is scratchy and scraping; pitch is high heard better with the diaphragm

Pulmonic Stenosis

A pathologic murmur; located 2nd and 3rd left interspaces; radiates if loud toward the left shoulder and neck; crescendo-decrescendo; associated findings include: severe stenosis, S2 split, P2 diminished, may hear right-sided S4; mechanism impair flow across the valve, increasing right ventricular after load. e.g atrial septal defect

Aortic Stenosis

A pathologic murmur; located at 2nd interspace, radiates often to the carotids, down the left sternal border, to the apex; crescendo-descrendo may be higher at the apex; associated findings include: delayed carotid upstroke, delayed A2; mechanism involves impaired blood flow across the valve increasing left ventricular afterload, causes are congenital, rheumatic and degenerative; e.g Marfan's syndrome

Hypertrophic Cardiomyopathy

A pathologic murmur; located at the 3rd and 4th left interspace; radiates down the left sternal border to the apex possibly to the base; decreases with squatting, increases with straining down Valsalva or standing; Associated findings include: S3 may be present, S4 often present at apex, carotid pulse quickly rises; *mechanism is ventricular hypertrophy* usually associated with unusually rapid ejection of blood from the left ventricle during systole.

Mitral Valve Prolapse

An abnormal systolic ballooning of part of the mitral valve into the left atrium from both leaflet redundancy and elongation of the chordae tendinae; common cardiac condition affecting about 2-3% of general population; equal prevalence in men and woman

Murmurs

Are abnormal heart sounds that are produced as a result of turbulent blood flow which is sufficient to produce audible noise.

Systolic Clicks

Are usually caused by mitral valve prolapse; usually are mid or late systolic. Murmur usually crescendos up to S2

Pathologic Murmur

Arises from a structural abnormality in the heart or great vessels of the heart; diastolic are always this type of murmur

Why listen to the aorta in the right side instead of the left where it exits?

Because it makes a loop on the right side before descending on the left side where it originates.

Atrioventricular / Semilunar

Because of their location, the tricuspid and mitral valves are often called the ______ valves. The aortic and pulmonic valves are often called ______ valves.

Blood Circulation in the Heart

Blood comes into the right atrium from the body, moves into the right ventricle and is pushed into the pulmonary arteries in the lungs. After picking up oxygen, the blood travels back to the heart through the pulmonary veins into the left atrium, to the left ventricle and out to the body's tissues through the aorta.

Mitral Stenosis

Diastole Murmur: located usually limited to the apex; radiates little to none; decrescendo low-pitched rumble (left lateral position) and mold; associated findings include: S1 is accentuated may be palpable at the apex, an opening snap often follows S2 and initiates the murmur, also mitral regurg. and aortic stenosis may be associated with this condition; mechanism involves the mitral valve failing to open sufficiently in diastole.

Aortic Regurgitation

Diastolic murmur; located 2nd to 4th left interspaces; radiates if loud to the apex perhaps to the right sternal border; decrescendo, may be mistaken for breath sounds; the murmur is best heard with the patient sitting, leaning forward, with breath held after exhalation; associated findings include: ejection sound may be present, S3 or S4 if present suggests severe regurg., arterial pulses are often bounding; *mechanism is the leaflets of the aortic valve fail to close completely during diastole, and blood regurgitates from the aorta back into the left ventricle resulting in volume overload.* e.g. widely known as the austin flint murmur

Right Ventricular Impulse: Hyperkinetic

Examples of causes include: anxiety, hyperthyroidism, severe anemia; located in the 3rd, 4th, or 5th left interspace, diameter is not relevant, amplitude is slightly more forceful, and normal duration

Left Ventricular Impulse: Hyperkinetic

Examples of causes include: anxiety, hyperthyroidism, severe anemia; normal location, diameter is -2cm, amplitude is more forceful tapping, duration is <2/3 systole

Left Ventricular Impulse: Volume Overload

Examples of causes include: aortic or mitral regurg., cardiomyopathy; location is displaced to the left possible downward toward apex, diameter is >2 cm., amplitude is diffuse, duration is often slightly sustained

Left Ventricular Impulse: Pressure Overload

Examples of causes include: aortic stenosis, hypertension; normal location, diameter >2 cm., amplitude is more forceful tapping, duration is sustained up to S2 (all of systole)

Right Ventricular Impulse: Volume Overload

Examples of causes include: atrial septal defect; located at the left sternal border, extending toward the left cardiac border, also subxiphoid, diameter not relevant, amplitude is slightly, markedly more forceful, duration is normal to slightly sustained

Right Ventricular Impulse: Pressure Overload

Examples of causes include: pulmonic stenosis, hypertension, located in the 3rd, 4th, or 5th, interspace also subxiphoid, diameter is not relevant, amplitude is more forceful, and duration is sustained

Crescendo/Descrendo

First rises in intensity, then falls; aortic stenosis

Grade Scale for Heart Murmur

Grade 1: very faint, heard only after listener has "tuned in", may not be heard in all position (only heard if pt. bears down, Valsalva maneuver) Grade 2: quiet but heard immediately after placing the stethoscope on the chest Grade 3: moderately loud Grade 4: loud, with palpable thrill (a tremor/vibration felt on palpation) Grade 5: very loud, with thrill, may be heard when stethoscope is partly off the chest Grade 6: very loud, with thrill, may be heard with stethoscope entirely off the chest *3/4 are most common*

Crescendo

Grows louder; mitral stenosis

Decrescendo

Grows softer; aortic regurg.

Plateau

Has the same intensity throughout; mitral regurg.

Standing

In mitral valve prolapse Several positions are recommended to identify the specific syndrome. ______ moves the click closer to S1

Squatting

In mitral valve prolapse several position are recommended to identify the specific syndrome. _______ delays the click and murmur.

right ventricular hypertrophy

In patients with Chronic Obstructive Pulmonary disease, the most prominent palpable impulse of PMI may be in the xiphoid or epigastric area as a result of ________ .

Korotkoff sounds

In the Valsalva maneuver, in healthy patients phase 2, the strain phase is silent and ______ are heard after straining is released, or during phase 4.

Left Lateral Decubitus

In this special maneuver ask the pt. to roll partly onto the left side into the ________ position; bring the left ventricle close to the chest wall at the PMI; this position accentuates a left sided S3 and S4 and mitral murmurs.

Aortic murmurs

In this special maneuver, ask the pt. to sit up, lean forward, exhale completely, and stop breathing in expiration; listening along the left sternal border with the diaphragm and at the apex; this position accentuates _______ murmurs.

Bisferiens Pulse

Increased arterial pulse with a double systolic peak; Causes include pure aortic regurgitation, combined aortic stenosis and regurgitation, hypertrophic cardiomyopathy.

Pathologic Splitting

Involves splitting during expiration and suggests heart disease

Physiologic Murmur

Is from ___ changes in body metabolism; similar in most ways to innocent murmurs; associated findings are possible signs of a likely cause; mechanism involves turbulence due to a temporary increase in blood flow in predisposing conditions such an anemia, pregnancy or hyperthyroidism; only systolic

Decreased or Absent A2 in the Right 2nd Interspace

Is noted in calcific aortic stenosis because of valve immobility. If A2 is inaudible, no splitting is heard.

Decreased or Absent P2

Is usually from the increased anteroposterior diameter of the chest associated with aging. It can also result from pulmonic stenosis

Innocent Murmur

Is without any detectable physiologic or structural abnormality; it is located 2nd to 4th interspaces between the left sternal border and the apex; radiates very little; intensity is grade 1-2; pitch is soft to medium; quality is variable; usually decreases or disappears on sitting. Associated findings include: none. *Mechanism is turbulent blood flow, probably generated by ventricular ejection of blood into the aorta from the left and occasionally the right ventricle.*

Diastole

It is the pressure that is exerted on the walls of the various arteries around the body in between heart beats when the heart is relaxed. Heart muscle is resting between beats and refilling with blood. Aortic closes, mitral opens ; falling between S2 and S2, mid-diastolic or late diastolic

Systole

It measures the amount of pressure that blood exerts on arteries and vessels while the heart is beating. Left ventricles contract; mitral closes, aortic opens; falling between S1 and S2, midsystolic, pansystolic holosystolic, late systolic

Physiologic Splitting

Listen for _______ splitting of S2 in the 2nd or 3rd left interspace. This normal splitting is accentuated by inspiration and usually disappears on expiration.

Aortic Ejection Sound

Listen for this sound at both the base and the apex; it may be louder at the apex and usually does not vary with respiration. This sound may accompany a dilated aorta or aortic valve disease from congenital stenosis or a bicuspid aortic valve.

Interpretation of JVP

Low venous pressure- low cardiac output, dehydration, blood loss High venous pressure- right heart failure, left heart failure, pulmonary hypertension, pericardial compression/tamponade *possible left carotid occlusion and mitral regurg.*

Paradoxical Pulse

May be detected by a palpable decrease in the pulse's amplitude on quiet inspiration. This pulse is found in pericardial tamponade and frequently in exacerbations of asthma and COPD. It is sometimes noted in constrictive pericarditis.

Ventricular Septal Defect

Murmur location is 3rd, 4th, and 5th interspaces; radiates often wide; intensity is often very loud with a thrill; Associated findings include S2 may be obscured by the loud murmur and the findings vary with the severity of the defect. *mechanism is which blood flows from the relatively high pressure left ventricle into the low pressure right ventricle through a hole*

Tricuspid Regurgitation

Murmur location is lower left sternal border; the intensity may increase slightly with inspiration. Associated findings include: JVP often elevated, the right ventricular impulse is increased in amplitude and may be sustained and an S3 may be audible along the lower left sternal border; *mechanism is when the tricuspid valve fails to close fully in systole*

Mitral Regurgitation

Murmur location is the apex; radiates to the left axilla; intensity does not become louder with inspiration; Associated findings include: S1 mostly normal, an apical S3 reflects volume overload; *mechanism is when the mitral valve fails to close fully in systole*

Irregularly Irregular

No discernible regularity; i.e. Atrial fibrillation, atrial flutter

Quadruple Rhythm Summation Gallop

Occasionally a patient has both an S3 and S4, producing a _____ of four heart sounds; at rapid heart rates, the S3 and S4 may merge into one loud extra heart sound called a _______

Increased Intensity of A2 in the Right 2nd Interspace

Occurs in systemic hypertension because of the increased pressure load; it also occurs when the aortic root is dilated, probably because the aortic valve is then closer to the chest wall.

Sporadic rate and rhythm

Premature or extra beats at random intervals, but normal underlying rhythm; i.e. Atrial or ventricular premature contractions, sinus arrhythmia

Small, Weak Pulse

Pulse Pressure is diminished; upstroke slowed and the peak prolonged. Causes include: decreased stroke volume & increased peripheral resistance e.g. such as heart failure, hypovolemia, and severe aortic stenosis.

Large, Bounding Pulse

Pulse Pressure is increased; the rise and fall may feel rapid, the peak brief. Increased stroke volume and decreased peripheral resistance; Causes include fever, anemia, hyperthyroidism, aortic regurgitation, arteriovenous fistulas, and patent ductus arteriosus, atherosclerosis.

Normal Pulse

Pulse is approx. 30-40 mm Hg; the contour is smooth and rounded

Pulsus Alternans

Pulse switches in amplitude from beat to beat even though the rhythm is basically regular; this indicates left ventricular failure and is usually accompanied by a left-sided S3.

Precordial Areas

RICS= right 2nd intercostal space= aortic valve LICS= left 2md intercostal space= pulmonic valve LBS= left sternal border/Erb's point (3rd, 4th ICD)= tricuspid valve, right ventricle Apex= 5th ICS on MCL (medial clavicular line)= mitral valve, left ventricle

Assessment of JVP

Raise head off bed to 30 degrees, turn patients head away from side you are inspecting, using tangential lighting observe for the pulsation of the internal jugular vein; identify the highest point of pulsation of the internal jugular vein, measure the height of the pulsation above the sternal angle

Jugular Venous Pressure

Reflects pressure in the right atrium, or central venous pressure and is best assessed from pulsations in the right internal jugular vein; pressure changes from right atrial filling, contraction, and emptying cause fluctuations in the JVP and its waveforms that are visible to the examiner.

Regularly Irregular

Regular pattern of cadences; i.e. Ventricular Premature contractions (ventricle bi/trigeminy)

Atrial or Nodal Premature Contractions (supraventricular)

Rhythm: A beat of atrial or nodal origin comes earlier than the next expected normal beat. A pause follows, and then the rhythm resumes. Heart Sounds: S1 may differ in intensity from the S1 of normal beats, and S2 may be decreased.

Ventricular Premature Contractions

Rhythm: A beat of ventricular origin comes earlier than the next expected normal beat. A pause follows, and the rhythm resumes. Heart Sounds: S1 may differ in intensity from the S1 of the normal beats, and S2 may be decreased. Both sounds are likely to be split.

Sinus Arrhythmia

Rhythm: The heart varies cyclically, usually speeding up with inspiration and slowing down with expiration. Heart Sounds: Normal, although S1 may vary with the heart rate.

Atrial Fibrillation and Atrial Flutter with Varying AV Block

Rhythm: The ventricular rhythm is totally irregular, although short runs of the irregular ventricular rhythm may seem regular. Heart Sounds: S1 varies in intensity.

Diminished S1

S1 is _____ in first-degree heart block and also ______ in mitral regurgitation and in heart failure or coronary heart disease.

Accentuated S1

S1 is ________ in tachycardia (high cardiac output states) and mitral stenosis. In this condition, the mitral valve is still open wide at the onset of ventricular systole and then closes quickly.

Normal Variations in S1

S1 is softer than S2 at the base (right and left 2nd interspaces). S1 is often but not always louder than S2 at the apex.

Split S1

S1 may be ______ normally along the lower left sternal border where the tricuspid component, often too faint to be heard, becomes audible; may sometimes be heard at the apex as well

Varying S1

S1_____ in intensity in complete heart block and also in any totally irregular rhythm like A-fib. Varying in loudness.

S3 Heart Sound

Sound also known as the "ventricular gallop" occurs just after S2 when the mitral valve opens allowing passive filling of the left ventricle; produced by a large amount of blood striking a very compliant left ventricle; heard best in the left lateral decubitus position or at the apex

S4 Heart Sound

Sound as known as the "atrial gallop" occurs just before S1 when the atria contract to force blood into the LV. If the LV is non-compliant and atrial contraction forces blood through the AV vales, an ___ is produced by the blood striking the LV.

S1 Heart Sound

Sound is a result of the closing of mitral and tricuspid valves simultaneously; is heard best at the tricuspid listening post, LSB 4th ICS, apex

S2 Heart Sound

Sound is a result of the closure of the aortic and pulmonic valves; termed A2 and P2; A2 sound is much louder than P2 therefore it is the main component of this heart sound; heard best over the base

Pulmonic Ejection Sound

Sound is heard best in the 2nd and 3rd interspace; when S1, usually relatively soft in this area, appears to be loud, you may be hearing this sound. Its intensity often decreases with inspiration; causes include: dilation of the pulmonary artery, pulmonary hypertension, and pulmonic stenosis.

Early Systolic Ejection Sounds

Sounds occur shortly after S1, coincident with opening of the aortic and pulmonic valves; they are relatively high in pitch, have a sharp, clicking quality, and are heard better with the diaphragm of the stethoscope. An ejection sound indicated cardiovascular disease.

Pathologic S3 or Ventricular Gallop

Sounds similar to physiologic S3; an S3 in adults over age 40 is usually _______, arising from high pressures and abrupt deceleration of inflow across the mitral valve at the end of the rapid filling phase of diastole. Causes include: decreased myocardial contractility, heart failure, and volume overloading.

Opening Snap

The _______ is a very early diastolic sound usually produced by the opening of a mitral valve stenosis

Bell

The _______ is more sensitive to the low-pitched sounds of S3 and S4 and the murmur of mitral stenosis; best to listen at the apex

Diaphragm

The ________ is better for picking up the relatively high-pitched sounds of S1 and S2, the murmurs of aortic and mitral regurg., and pericardial friction rubs; best to listen at the precordium

right ventricle

The ________ occupies most of the anterior cardiac surface; this chamber and the pulmonary artery form a wedge-like structure behind and to the left of the sternum; the inferior border of this chamber lies below the sternum and the xiphoid process.

Circulation of the heart

The heart constantly pushes oxygen-rich blood to the brain and extremities and transports oxygen-poor blood from the brain and extremities to the lungs to gain oxygen.

Point of Maximal Impulse

The left ventricle forms the lateral margin of the heart, its tapered inferior tip is often termed the cardiac "Apex" and is clinically important because it produces the _____. This space locates the left border of the heart and is normally found in the 5th interspace; it is not always palpable, even in a healthy patient.

Right-sided S4

The less common _______ is heard along the lower left sternal border or below the xiphoid; if often gets louder with inspiration; causes include: pulmonary hypertension and pulmonic stenosis.

Gallop

The term _______ comes from the cadence of three heart sounds, especially at rapid heart rates, and sounds like "Kentucky"

base of the heart

The ventricle narrows *superiorly* and joins the pulmonary artery at the level of the sternum or _____, a clinical term that refers to the superior aspect of the heart at the right and left 2nd interspaces next to the sternum.

Bigeminal Pulse

This disorder of rhythm may mimic pulsus alternans; this is caused by a normal beat alternating with a premature contraction. The stroke volume of the premature beat is diminished in relation to that of the normal beats, and the pulse varies in amplitude accordingly.

Valsalva Maneuver

This special technique involves forcible exhalation against a closed glottis causing increased intrathoracic pressure; the murmur of hypertrophic cardiomyopathy is the *only* systolic murmur that increases during the strain phase of this technique, due to increased outflow tract obstruction

Continuous murmur

This type of murmur begins in systole and extends into all or part of diastole; congenital patent ductus arteriosus and Av fistulas (common in dialysis pts.) produce this type of murmur.

Midsystolic murmur

This type of murmur normally begins after S1 and stops before S2; typically they arise from blood flow across the semilunar valves; the gap and stop is what confirms this murmur as _____

Middiastolic murmur

This type of murmur starts a short time after S2, it may fade away or merge into a late diastolic murmur; reflects turbulent flow across the atrioventricular valves.

Early diastolic murmur

This type of murmur starts immediately after S2, without a discernible gap and then usually fades into silence before the next S1; typically accompany regurg. flow across incompetent semilunar valves.

Late diastolic murmur

This type of murmur starts late in diastole and typically continues up to S1

Pansystolic murmur

This type of murmur starts with S1 and stops at S2, without a gap between murmur and heart sound; often occur with regurg. (backward) flow across the ventricular valves.

Late systolic murmur

This type of murmur usually starts in mid- or late systole and persists up to S2; this is the murmur of mitral valve prolapse and is often preceded by a systolic click

Wide Splitting

This type of pathological splitting can be a split in S1 or S2 and refers to an increase in the usual splitting that persists throughout the respiratory cycle; Causes include pulmonic stenosis and in mitral regurgitation.

Paradoxical or Reversed Splitting

Type of pathological splitting; Refers to splitting that appears on expiration and disappears on inspiration; delayed closure of the aortic valve. The most common cause is if a left bundle branch block.

Fixed Splitting

Type of pathological splitting; Refers to wide splitting that does not vary with respiration; it occurs in atrial septal defect and right ventricular failure.

Increased Intensity of P2

When P2 is equal to or louder than A2, suspect pulmonary hypertension; other causes include a dilated pulmonary artery and an atrial septal defect.

Physiologic S3

You will detect __________ frequently in children and in young adults to the age of 35 or 40; it is common during the last trimester of pregnancy; occurring in diastole during rapid ventricular filling, it is later than the opening snap, dull and low in pitch, and heard best at the apex in the left lateral decubitus position.

Mitral / Aortic

____ sounds radiate to axilla from the apex ____ sounds radiate to carotids/neck from base

Normal Heart Rate and Rhythm

_____ includes: Sinus rhythm 60-90, second-degree AV block 60-100, atrial flutter with a regular ventricular response 75-100

Left Ventricular Impulse

_____ ventricular impulse is usually the PMI and commonly described as Location: 4th or 5th interspace, at the midclavicular line Diameter: discrete, >2 cm. Amplitude: brisk and tapping Duration: <2/3 systole

Slow Heart Rate and Rhythm

______ includes: Sinus bradycardia <60, second-degree AV block 30-60, complete heart block <40

Right Ventricular Impulse

______ ventricular impulse is normally not palpable beyond infancy

Fast Heart Rate and Rhythm

________ includes: Sinus tachycardia 100-180, supraventricular (atrial or nodal) tachycardia 150-250, atrial flutter with a regular ventricular response 100-175, ventricular tachycardia 110-250

Thrills

produced by loud murmurs- feel like the purring of a cat

Hypertrophic Cardiomyopathy/ Subaortic stenosis

systolic murmur very similar to aortic stenosis; louder on LSB than apex; louder when filling of the LV is decreased, softer with LV increased filling *young athletes die from this*; bear down= Valsalva, want to release pressure from narrowing arteries causes more blood large spaces produce less sound --> increases with squatting

Bruits

the unusual sound that blood makes when it rushes past an obstruction (turbulent flow) in an artery when the sound is auscultated.