Date post: | 21-Jul-2016 |
Category: |
Documents |
Upload: | thilak-jayalath |
View: | 11 times |
Download: | 1 times |
Examination of Cardiovascular
System
First impression
Inherited syndromes
•Down's syndrome (PDA, ASD & VSD)
•Marfan's syndrome (aortic dissection, valve disease)
•Turner's syndrome (aortic coarctation & aortic stenosis)
Ankylosing spondylitis (aortic regurgitation)
Acromegaly (hypertension & cardiomegaly)
Other syndromes
Down’s syndrome
Marfan ’s syndrome
Turner ’ s syndrome
Turner ’ s syndrome
Acromegaly
Acromegaly
General Examination
BreathlessnessIn pain
Febrile
Pallor
Xanthelesma
Xanthelesma
Cleft ear lobes
Central cyanosis
Dental care
Thyroid enlargement
Central cyanosis
Clubbing of the fingers
Splinter heamorrhages
Splinter haemorrhages
Osler’s nodes
Janeway’s lesions
Ankle oedema
Sacral oedema
PulsePresence or absenceRate Rhythm Character
Presence of bruits
Jugular venous pulse
Jugular venous pressure
The internal jugular vein provides information about right atrial and right ventricular function
The jvp can be discriminated from the carotid pulse because:
It cannot be palpated
It has a complex wave form; it is usually seen to flicker twice within each cardiac cycle
It moves on respiration, normally decreasing on inspiration and rising on expiration
Mild pressure applied to the base of the neck obliterate its pulsations
Mild pressure applied over the liver will expel more blood into the right side of the heart and elevate the jvp, a positive hepato-jugular reflex
Jugular venous wave pattern
The jvp is described in terms of:
• Height
• character
The height of the jvp is expressed as the vertical distance from the manubriosternal angle to the maximum height of pulsations in the internal jugular vein with the patient semi-recumbent at an angle of 45 degrees
It is normally less than 3 cm.
This equates to a right atrial pressure of 8 cm of water as in this position, the manubriosternal angle is about 5 cm above the centre of the right atrium
Causes of a raised jvp
• increased right ventricular filling pressure
• obstruction of blood flow from the right atrium to the right ventricle
• superior vena caval obstruction
• positive intrathoracic pressure
Abnormal waves
Abnormally large a waves indicate increased resistance to right atrial emptying from right ventricular hypertrophy, as in severe pulmonary stenosis, or tricuspid stenosis.
Abnormal waves
A waves are absent in atrial fibrillation, since coordinated atrial contraction is necessary to produce them,
Abnormal wavesCannon waves are very large a waves that occur when the right atrium contracts against a closed tricuspid valve.
They occur irregularly in complete heart block and ventricular tachycardia, conditions that are characterised by atrioventricular dissociation with random occasional simultaneous atrial and ventricular contractions.
An exaggerated x descent indicates that blood is being ejected from a restricted pericardial cavity, for example, because of cardiac tamponade or constrictive pericarditis without calcification.
A slow y descent may be seen in tricuspid stenosis and right atrial myxoma.
Examination of the precordium
Scars, The midline scar of a sternotomy The left lateral scar of a mitral valvotomy
Deformity
Pacemaker
Visible apex beat or other pulsation
Inspection
Pectus excavatum
PalpationApex beat
Parasternal haeve
Palpable heart sounds Plapable murmurs
Apex beats different types
Sustained or heaving apex beat is caused by pressure overload
• aortic stenosis,
• severe hypertension.
Apex beats different types
Tapping apex beat seen in
Mitral stenosis
Apex beats different types
Thrusting displaced apex beat is caused by volume overload: an active large stroke volume ventricle
•Aortic regurgitation•Mitral regurgitation •Left to right shunts.
Apex beats different types
Double or triple impulse occur in
Hypertrophic obstructive cardiomyopathy
Apex beats different types
An impalpable apex beat •Obesity •Overinflated chest •Pericardial effusion •Dextrocardia
Apex beat
Parasternal heave is detected by placing the heel of the hand
over the left parasternal region. In the presence of a
heave the heel of the hand is lifted off the chest wall with
each systole.
Parasternal haeve
Parasternal heave is caused by:
Right ventricular enlargement
Severe left atrial enlargement which pushes the right ventricle forwards
Thrill
These are palpable murmurs
They always indicate an organic defect
The area where the thrill is felt strongest gives clues as to the aetiology of the thrill
Thrills may be Systolic or diastolic:
Best felt site suggest the oetiology
Systolic:
• Apex mitral incompetence • at 3rd or 4th interspace vsd• At base on right aortic stenosis • at base on the left pulmonary stenosis
• Below left clavicle - pda
Diastolic:
Apex mitral stenosis
Accurate and sensitive auscultation
of the praecordium requires experience
Location of heart valves
Auscultation should begin in the mitral region:
Use the bell initially to detect the low frequency sounds of mitral stenosis or a third heart sound
Use the diaphragm to detect the higher frequency sounds of mitral incompetence or a fourth heart sound
Using the bell and diaphragm, listen in the following locations
Tricuspid area Pulmonary area
Aortic area
Never forget toAuscultate over the mitral area in left lateral position in expiration with the bell to find mid diastolic murmur in mitral stenosis
Never forget toAuscultate over the lower left sternal edge in expiration , in seated and bent forward position, with the diaphram to find early diastolic murmur in aortic incompetence
Heart sounds
There are two major groups of heart sounds They are classified according to their mechanism,
Valvular
Ventricular filling
Valve sounds
These include:
• First heart sound• Second heart sound • ejection sounds • opening snaps
The first heart sound is caused by the closing of the mitral valve and the closing of the tricuspid valve
It is heard loudest at the apex.
Possible causes of a soft first heart sound include
• Mitral regurgitation • low blood pressure, • rheumatic carditis • severe heart failure • left bundle branch block
Loud first sounds
A loud first heart sound occurs when the leaflets are wide open at the end of ventricular diastole and shut forcefully at the beginning of ventricular systole.
Causes of loud first heart sound
• Atrial fibrillation
• short diastole – tachycardia
• Atrial premature beat
• Mitral stenosis where high left atrial pressure delays mitral valve closure
If the blood flow from atria to ventricles varies from one beat to the next, then the intensity of the first heart sound will change accordingly
Causes include
Varying duration of diastole
Complete atrioventricular block
A soft, or absent, a2 is heard in:Poorly mobile cusps –
• calcification as occurs in some forms of aortic stenosis
• dilatation of the aortic root - syphilitic aortitis
A soft, or absent, p2 is heard in:
Pulmonary stenosis
Loud second heart sounds can be loud a2 or a loud p2.
Loud a2 occurs in systemic hypertension where there is a dilated proximal aorta
A loud p2 is heard in pulmonary hypertension
Splitting of second heart sound
A2 and p2 separate on inspiration(P2 following a2)
This is because of the increased right ventricular stroke volume that occurs as the result of increased venous return
The second heart sound is widely split if there is an early a2 or if the p2 is delayed.
Early A2 can occur in
• Mitral regurgitation
• Ventricular septal defect
Delayed p2 –
Possible causes include :-
• Right bundle branch block• Pulmonary stenosis • Atrial septal defect
Fixed splitting
Splitting of seond heart sound in both inspiration and expiration
Reversed splitting
In this condition, p2 occurs before a2
On expiration, a2 is delayed such that it occurs after p2
Inspiration causes p2 to be delayed and the split is diminished.
Possible causes of a delayed a2
• Left bundle branch block • systolic hypertension • severe aortic stenosis or hocm • patent ductus arteriosus • left heart failure
Ejection clicks
These are caused by the opening of the aortic and pulmonary valves.
These sounds are high pitched and often described as clicky.
They occur in early systole and are best heard with a rigid diaphragm chest piece.
Opening snaps
In certain pathological states the av valves open more rapidly than normal, this results in an audible opening snap.
A mitral opening snap may be caused by:
Mitral stenosis with a mobile valve
Rapid mitral flow causes a soft snap in left to right shunts such as Vsd or pda.
Severe mitral regurgitation
A tricuspid opening snap is rare and may be caused by:
• Rheumatic stenosis
• Atrial septal defect with increased tricuspid flow
Filling sounds
These sounds are of much lower frequency than the valve sounds and may be difficult to hear.They are best heard with the bell gently applied to the chest and are described as a dull thud becoming palpable when loud.
Ventricular filling sounds include:Rapid filling (third)
Atrial (fourth)
Third heart sound
This heart sound is caused by rapid ventricular filling in early diastole.
The third sound is normally audible in children, with the intensity diminishing with age.
The third heart sound becomes inaudible (but recordable) in normal subjects in middle age with increasing ventricular stiffness.
Fourth heart sound
The fourth heart sound is due to atrial contraction inducing ventricular filling towards the end of diastole.
They are never audible in normal subjects.
A fourth heart sound is the result of powerful atrial contraction filling an abnormally stiff ventricle.
Left atrial heart sound is maximal at the apex, with possible causes including:
• Left ventricular hypertrophy • fibrotic left ventricle • hypertrophic cardiomyopathy
Right atrial heart sound is maximal at the lower left sternal edge and on inspiration.
This may occur in
Right ventricular hypertrophy
MurmursHeart murmurs are caused by turbulent blood flow through valves or ventricular outflow tracts
Characteristics of heart murmurs
TimingDurationCharacter and pitchIntensityLocationRadiation
Murmurs are recorded in six gradations:
1/6 murmur is just audible by an expert in optimal conditions
2/6 is quiet 3/6 is moderately loud
4/6 is markedly loud , accompanied by a thrill
5/6 is very loud with a thrill 6/6 is audible without a stethoscope
With reference to valvular lesions
Systolic murmurs imply incompetence of atrioventricular valve or stenosis/sclerosis of semilunar valve.
Diastolic murmurs imply stenosis of atrioventricular valve or incompetence of semilunar valve
Left ventricular ejection murmurs are maximal at the aortic area, lower left sternal edge and apex.
Possible causes include:
• Aortic stenosis
• Hypertrophic obstructive cardiomyopathy
• aortic cusp sclerosis
Ejection systolic murmur maximal over the aortic area:
Aortic stenosis Aortic sclerosis Coarctation of the aorta
Hypertrophic cardiomyopathy
Ejection systolic murmur maximal over the pulmonary area:
• Innocent • pulmonary stenosis • pulmonary hypertension • atrial septal defect
Pansystolic murmurs
Pansystolic murmurs occur throughout systole
Caused by:
• Mitral regurgitation
• Ventricular septal defect
• tricuspid regurgitation
Diastolic murmursEarly diastolic murmurs
Mid-diastolic murmurs
Early diastolic murmursAortic regurgitation - maximal at the 4th interspace below the aortic valve. Maximal if the patient leans forwards. Radiates to the back.
Pulmonary regurgitation - maximal about the third left space.
Mid diastolic murmursMitral stenosis - maximal at the apex with the patient inclined to the left. The murmur begins after the opening snap. The murmur is long if severe and short if mild.
Tricuspid stenosis - maximal at the lower left sternal edge. The murmur is increased by inspiration.
A murmur mimicking mitral stenosis may occur when there is greatly increased flow across the mitral valve. This may occur in
• mitral regurgitation,
•Ventricular septal defect
•Patent ductus arteriosus
Continuous murmur
These occur when there is a communication in the circulation with a continuous pressure gradient throughout the cardiac cycle.
Continuous murmurs are often maximal in late systole
Causes of a continuous murmur include:
• Patent ductus arteriosus • aortic sinus of valsalva aneurysm rupturing into the right heart • pulmonary arteriovenous communications• Bronchial artery anastomosis in pulmonary atresia• Artificial ducts • prosthetic valve• Venous hum
Innocent murmurs
Many babies and children have heart murmurs in the absence of any structural abnormality
If a murmur has any of the following characteristics then it probably is not innocent:
• Pansystolic • diastolic • loud or long • associated with a thrill or cardiac symptoms
.`
Some hints concerning listening for murmurs:
Time the cardiac cycle by palpating one of the patient's carotid arteries
The bell is good for hearing low-pitched sounds e.G. Mitral stenosis. It should be applied very gently to the skin
The diaphragm is good for listening to high pitched mumurs e.G. Aortic regurgitation
Some hints concerning listening for murmurs:
Left heart murmurs are louder in expiration
Right heart murmurs are louder in inspiration
Exercise makes a mitral stenotic murmur louder
END